Herts Valleys Clinical Commissioning Group Primary Care Commissioning Committee Part 2 in Public Thursday 19 November 2020, 3.00Pm Via Webex

Herts Valleys Clinical Commissioning Group Primary Care Commissioning Committee Part 2 in Public Thursday 19 November 2020, 3.00pm Via Webex

Note concerning HVCCG management of conflicts of interest.

A conflict of interest occurs where an individual’s ability to exercise judgement, or act in a role is, could be, or is seen to be impaired or otherwise influenced by his or her involvement in another role or relationship. In some circumstances, it could be reasonably considered that a conflict exists even when there is no actual conflict. In these cases it is important to still manage these perceived conflicts in order to maintain public trust.

Members and attendees of the Committee are reminded of their responsibilities.

To ensure transparency and openness, individuals should notify the Chair of any potential conflicts of interest in relation to agenda items, even if the interest is already formally recorded.

January 2019

The Nolan Principles In May 1995, the Committee on Standards in Public Life, under the Chairmanship of Lord Nolan, established the Seven Principles of Public Life, also known as the “Nolan principles”. These principles are the basis of the ethical standards expected of all public office holders.

The Herts Valleys CCG Constitution recognises that in all its work it must seek to meet the highest expectations for public accountability, standards of conduct and transparency. It will therefore ensure that the Nolan principles, set out below, are taken fully into account in its decision making and its policies in relation to standards of behaviour.

1. Selflessness. Holders of public office should act solely in terms of the public interest. 2. Integrity. Holders of public office must avoid placing themselves under any obligation to people or organisations that might try inappropriately to influence them in their work. They should not act or take decisions in order to gain financial or other material benefits for themselves, their family, or their friends. They must declare and resolve any interests and relationships. 3. Objectivity. Holders of public office must act and take decisions impartially, fairly and on merit, using the best evidence and without discrimination or bias. 4. Accountability. Holders of public office are accountable to the public for their decisions and actions and must submit themselves to the scrutiny necessary to ensure this. 5. Openness. Holders of public office should act and take decisions in an open and transparent manner. Information should not be withheld from the public unless there are clear and lawful reasons for so doing. 6. Honesty. Holders of public office should be truthful. 7. Leadership. Holders of public office should exhibit these principles in their own behaviour. They should actively promote and robustly support the principles and be willing to challenge poor behaviour wherever it occurs.

January 2019

Herts Valleys Clinical Commissioning Group Draft Agenda – Part 2: Meeting in Public Primary Care (Medical Services) Commissioning Committee (PCCC) 19 November 2020, 3.00-4.30pm, via Microsoft Teams

Committee quorum: One Lay member (Chair or Vice Chair), Two executive voting representatives, One non-conflicted clinician voting member.

Part 1 – MATTERS TO BE CONSIDERED WITHOUT THE PUBLIC AND PRESS PRESENT In accordance with section 1 (2) Public Bodies (Admissions to Meetings Act 1960), The Committee resolves that: Representatives of the press, and other members of the public, be excluded from this meeting having regard to the confidential nature of the business to be transacted, publicity on which would be prejudicial to the public interest.

Part 2 – MATTERS TO BE CONSIDERED WITH THE PUBLIC AND PRESS PRESENT 15:00 1 Chair’s introduction and apologies for absence To note Chair 2 Interests to declare To note Chair 3 Minutes of previous meeting For approval Chair 4 Matters arising For discussion Chair 5 Terms of Reference approved by the board To note Chair 6 Committee work plan For discussion Chair Strategy and Performance 15:20 7 Primary Care Directorate Report For assurance Michelle Campbell 15.40 8 GP Forward View workforce plan update For assurance Joyce Sweeney 15:50 9 PCN Development Funding Allocations proposal For approval Michelle Campbell 16.00 10 Flu programme uptake report For assurance Lynn Talbot 16:10 11 Finance report For discussion Elke Taylor 16:20 12 PMOT summary paper For approval Sarah Crotty Closing items 16:25 13 Reflection on how conflicts of interest were For agreement Chair managed in the meeting 14 Reflection on equality and diversity in relation to decisions made 15 New risks identified 16 Items for cascade to localities and staff Next meeting: 21 January 2021, 14.30-16.30

Item C3

Draft Minutes

Meeting : Primary Care Commissioning Committee (PCCC) Part 2 held in public Date : 20 August 2020 Time : 2.30pm Venue : Via Webex

Present: Andrew Anderson (AA) Independent GP Member Daniel Carlton-Conway (DCC) GP Board Member and Locality Chair – St Albans and Harpenden Lynn Dalton (LD) Director of Primary Care David Evans (DE) Managing Director (Deputy Chair of Meeting) Trevor Fernandes (TF) GP Board Member – Dacorum and Deputy Clinical Chair Clare Molloy (CM) Deputy Director of Nursing and Quality Alan Pond (AP) Chief Finance Officer Thelma Stober (TS) Board Lay Member (Chair of meeting) In attendance: Michelle Campbell (MC) Assistant Director of Primary Care and Localities Sarah Crotty (SC) Assistant Director, Pharmacy and Medicines Optimisation (PC/68-69/20) Mike Harrison (MH) Co-CEO, BHMK LMC Sundera Kumara-Moorthy (KMo) Healthwatch Hertfordshire Representative Katy Patrick (KP) Interim Head of Corporate Governance (Minutes) Nicola Peters (NP) Head of Finance (PC/XX/20 only) Ola Sijuwade (OS) Contracting Manager – Primary Care, NHSE/I Janet Weir (JW) Senior Pharmaceutical Advisor (to PC/69/20) John Wigley (JW) Patient Representative

PART 2: MATTERS TO BE CONSIDERED WITH THE PUBLIC AND PRESS PRESENT PC/60/20 Chair’s introduction and apologies for absence (Chair) 60.1  Apologies for absence had been received from committee members: Alison Gardner; Asif Faizy; Jane Halpin – David Evans to deputise; Jane Kinniburgh – Clare Molloy to deputise; Paul Smith.  Apologies for absence had been received from regular attendees: David Barter & Cathy Galione, NHSE – Ola Sijuwade to deputise; Nicky Williams, LMC – Mike Harrison, Co-CEO to attend; Jim McManus, HCC; Elke Taylor – Nicola Peters to deputise; Sarah Crotty – Janet Weir to deputise.  The meeting was quorate.

PC/61/20 Interests to declare (Chair) 61.1  The schedule of interests declared in advance of the meeting had been reviewed by the chair and LD prior to the meeting and are attached as an appendix to these minutes.  There were two items where HVCCG GPs had declared conflicts requiring action. Clinical input would be provided by AA, LD and CM.

PC/62/20 Minutes of previous meeting (Chair) 62.1  The minutes of the meeting held on 18 June 2020 were reviewed. 62.2 The Committee accepted the minutes as a true record of the meeting

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PC/63/20 Matters arising (Chair) 63.1 Two actions had been completed and closed. PC/12.4/20 Finance report is on the agenda for today’s meeting.

PC/64/20 Committee work plan 2020/21 64.1 The committee noted the updated work plan.

PC/65/20 Director of Primary Care report (LD) 65.1  This paper provides the committee with assurance about work taking place in primary care, localities and all work streams.  All localities have now reinstated regular meetings.  Locality plans are being reviewed in the light of Covid19. They were originally signed of 18 months ago. A paper is being developed for discussion at the ICP board in September.  A clinician user group is working through functionality of the GEMIMA risk stratification tool to identify patients most at risk. GEMIMA training will be rolled out to practices in September and PCN Clinical Directors are undertaking both Population Health and Risk Stratification training.  Home visits have been arranged for shielding patients who would normally come into practices.  Extended Access schemes were paused and repurposed to support the technology to allow non face to face consultations. Herts Urgent Care (HUC) have confirmed that their upgrade to version 3.31 of Adastra to support GP Connect, which will enable direct booking from NHS 111 into vacant appointments in Extended Access sessions, has been successful and testing can now begin with HUC and the providers. Implementation meetings are planned to take place before the end of August 2020 with a phased rollout in September to ensure the system has been robustly tested and is in place to support the system ahead of winter and a potential second peak of Covid-19.  The pan-Hertfordshire Primary Care Outbreak Cell has been established with multi-agency representation. An appendix to the Business Continuity Plan template is being developed to make it clear what primary care should do in the event of an outbreak of Covid19.  The ICS workforce group continues to work on its strategy and is planning a soft launch.  A primary care virtual awards ceremony has been planned for late October to celebrate success and share learning. 65.2 The following points were raised in discussion:  It is good to see that necessity has moved forward virtual consultations in primary care but the CCG recognises the need to look after those groups who do not have digital access. All programmes of work have been reviewed, including work with care homes and people with learning disabilities, to ensure that support is provided with any issues that arise.  Enhanced Effective Resource Management meetings have been stepped back up with the support of data from GEMIMA. The intention is to share learning on primary care management and development during Covid and extend to providers in the wider system. 65.3 The committee noted the report.

PC/66/20 Delegated Commissioning: NHSE/I revised ICS support arrangements (OS) 66.1  This report brings information to the committee about the primary care staff resource allocation to the HWE ICS area. This represents the proposed core offer to support ICS and CCG primary care team in their delivery of delegated responsibilities. A MoU is awaiting sign off pending agreement on the financial core offer which is still being discussed. The same offer is being made to all CCGs.  NHSE will be working with all three CCGs to ensure that they are supported effectively.  There is one other matter to raise with the committee: an extension will be required for the contracting arrangements for interpreting and translating which are due to expire in March 2021. There would be no local cost pressure and learning from experience during Covid19 2 | P a g e

would be applied. The CCG communications and engagement team has been contacted to identify appropriate cohorts of patients to be consulted. 66.2 The following points were raised in discussion:  There has been detailed work behind the scenes to avoid any CCGs declining to sign up to the MoU.  Further communication is required to inform practice participation groups about the proposed extension of the interpreting and translation service contract. 66.3 The committee noted the content of the report.

PC/67/20 Finance report (NP) 67.1  The report relates to Month 3 so the job titles and names are now out of date.  There has been a different financial regime in place to respond to the emergency period.  NHSE took responsibility for block contracts with providers and imposed on the CCG budgets for months 1 to 4 based on the estimate of 2019/20 outturn.  The unusual arrangements have led to some anomalies in the reporting schedule that will need to be adjusted.  To date £14m of Covid19 costs are being reported with the largest expenditure being transfer of patients from the acute trust, continuing healthcare costs and care home beds.  Months 5 and 6 will replicate Months 1 to 4.  Months 7 to 12 will require financial plans to be put in place.  More detail will be available in future reports about Covid19 costs in primary care. 67.2 The following points were raised in discussion:  The CCG is aware of the potential for legal challenges in relation to discharge from hospital to care homes during the Covid peak. A number of different government statutory bodies could be involved but liability is likely to be picked up nationally: no financial provision is being made locally. 67.2 The committee noted the report.

PC/68/20 PMOT summary report (JW) 68.1  The regular meetings for MOCL and HMMC have been held virtually. There are no resource implications arising from MOCL decisions. Implications of decisions taken at HMMC are outlined in the report. 68.2 The following points were raised in discussion:  Although there are no financial resource implications for the CCG in relation to shared care arrangements there is potential for an increase in primary care work. The ECF however makes provision for shared care. 68.3 The committee ratified the decisions taken by MOCL and HMMC subject to the query raised by LMC about primary care resource.

PC/69/20 PMOT LIS achievements (JW) 69.1  The proposal was agreed by the Director of Primary Care and Acting Chief Finance Officer at the end of February 2020 and therefore did not consider the impacts of Covid19. Where data is missing payments will be made based on available data.  A query was raised in relation to Edoxoban switches – to be addressed outside the meeting.  Four challenges have been received and are subject to standard processes. The majority of members were content with the decisions. 69.2 The committee agreed the report recommendation subject to the clarification noted above. JW and SC left the meeting PC/70/20 Reflection on how conflicts of interest were managed in the meeting (Chair) 70.1 The committee noted that all conflicts of interest were identified in advance of the meeting, discussed by the Chair and Executive lead, reported in appendix 1 including agreement about how they would be managed according to HVCCG policy.

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PC/71/20 New risks identified in the meeting (Chair) 71.1  Risks in relation to vulnerable patients were raised and addressed.

PC/72/20 Items for cascade to localities and staff (Chair) 72.1  Normal PC communications have already shared information about changes to the delegated commissioning arrangements and will be cascaded to all practices.

PC/73/20 Reflection on equality and diversity in relation to decisions made 73.1  EDI matters were addressed where relevant.

PC/74/20 There was no further business and the meeting closed at 3.23PM

Date and time of next meeting Thursday 19 September 2020, 2.30pm, via Webex.

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General Interests Declared: Name Financial Non-financial professional Non-financial personal Indirect Andrew Anderson  GP Partner in Octagon medical practice at  Clinical Lead for Urgent Care Cambridge and Jenner Health Centre Whittlesey, Peterborough CCG Peterborough  Independent GP advisor to West Essex CCG  Do out of hours work as GP for Herts Urgent  Ceased working for the NICE Indicator Care in Cambridge and Peterborough advisory committee in December 2018 Daniel Carlton- Conway  GP in St Albans & Harpenden locality.  Federation STAHFED.  Practice in a primary care network.  Prescriber. Asif Faizy  GP in Watford & Three Rivers locality  Member of federation  Prescriber Trevor Fernandes  GP in Dacorum Practice – Parkwood Surgery  Patient of Berkhamsted Group Practice  Part of Federation.  Prescriber. Alison Gardner  Registered at the Lodge Surgery in Redbourn.  Redbourn Parish Councillor Thelma Stober  Patient at Gossom End Surgery Jill Ainsworth-Beardmore  Patient registered at Lincoln House Surgery, Hemel Hempstead. Sundera Kumara-Moorthy  Vice Chairman, Trustee/Director,  Patient registered with Redhouse Group GP Healthwatch Hertfordshire Practice, Radlett  Trustee/Director, POhWER Part 2 – In Public Agenda item Aim Specific interests declared How managed 7. Director of Primary Care report For assurance Trevor Fernandes No action necessary. Report for assurance. GP partner in Herts Valleys 8. Delegated Commissioning: NHSE&I revised ICS support For information None arrangements 9. Finance report For discussion None 10. PMOT summary paper For approval Trevor Fernandes: Conflicted individuals did not participate in the decision. Clinical input GP Prescriber provided by AA, LD and CM. 11.PMOT LIS achievements 19/20 For approval Alan Pond: Indirect potential interest. Conflicted individuals did not participate in the decision. Clinical input My Partner (Dr Corina Ciobanu) is a GP Partner in Herts Valleys CCG (at provided by AA, LD and CM. Haverfield Surgery, Kings Langley) and is Chair of the Dacorum Locality and she could benefit under the agenda item. Daniel Carlton-Conway: Direct financial interest. My practice may benefit from this decision. Trevor Fernandes: Direct financial interest Practice gets paid Nil returns i.e. no specific interests declared [*Committee member] Thelma Stober * Jane Halpin* Lynn Dalton* Paul Smith* David Evans * Sundera Kumara Moorthy Clare Molloy * Janet Weir Michelle Campbell Sue Fogden Andrew Anderson* Nicola Peters Apologies for meeting received [*Committee member] Alison Gardner* Jane Kinniburgh* (Clare Molloy to deputise) Elke Taylor (Nicola Peters to deputise) David Barter, NHSE Cathy Galione, NHSE ( Ola Sijuwade to deputise) Nicky Williams, LMC ( Mike Harrison, Co-CEO to deputise) Sarah Crotty (Janet Weir to deputise) Asif Faizy* Jim McManus, HCC

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Herts Valleys CCG Primary Care (Medical Services) Commissioning Committee - last updated 09.11.2020 Private / Reasons not completed by original completion date Status Action Log Date of Meeting Subject Action Responsible Officer Due Date Comments Public Open No outstanding actions NHS Herts Valleys Clinical Commissioning Group Primary Care Commissioning Committee V1.5 Terms of reference Introduction

1. Simon Stevens, the Chief Executive of NHS England, announced on 1 May 2014 that NHS England was inviting CCGs to expand their role in primary care commissioning and to submit expressions of interest setting out the CCG’s preference for how it would like to exercise expanded primary medical care commissioning functions. One option available was that NHS England would delegate the exercise of certain specified primary care (medical services) commissioning functions to a CCG. 2. In accordance with its statutory powers under section 13Z of the National Health Service Act 2006 (as amended), NHS England has delegated the exercise of the functions specified in Schedule 2 to these Terms of Reference to Herts Valleys CCG. The delegation is set out in Schedule 1. 3. The CCG has established the Herts Valleys CCG Primary Care (Medical Services) Commissioning Committee (“The Committee”). The Committee will function as a corporate decision-making body for the management of the delegated functions and the exercise of the delegated powers.

Statutory Framework

4. NHS England has delegated to the CCG authority to exercise the primary care commissioning functions set out in Schedule 2 in accordance with section 13Z of the NHS Act. 5. Arrangements made under section 13Z may be on such terms and conditions (including terms as to payment) as may be agreed between the Board and the CCG. 6. Arrangements made under section 13Z do not affect the liability of NHS England for the exercise of any of its functions. However, the CCG acknowledges that in exercising its functions (including those delegated to it), it must comply with the statutory duties set out in Chapter A2 of the NHS Act and including:

a) Management of conflicts of interest (section 14O); b) Duty to promote the NHS Constitution (section 14P); c) Duty to exercise its functions effectively, efficiently and economically ( section 14Q); d) Duty as to improvement in quality of services and premises (section 14R); e) Duty in relation to quality of primary medical services (section 14S); f) Duties as to reducing inequalities (section 14T); g) Duty to promote the involvement of each patient (section 14U); h) Duty as to patient choice (section 14V); i) Duty as to promoting integration (section 14Z1); j) Public involvement and consultation (section 14Z2).

Primary Care Commissioning Committee Terms of Reference v 1.5 August 2020

7. The CCG will also need to specifically, in respect of the delegated functions from NHS England, exercise those in accordance with the relevant provisions of section 13 of the NHS Act.

8. The Committee is established as a committee of the Board of Herts Valleys CCG in accordance with Schedule 1A of the “NHS Act”.

9. The members acknowledge that the Committee is subject to any directions made by NHS England or by the Secretary of State.

Role of the Committee

10. The committee has been established in accordance with the above statutory provisions to enable the members to make collective decisions on the review, planning and procurement of primary care services in west Hertfordshire, under delegated authority from NHS England.

11. In performing its role the committee will exercise its management of the functions in accordance with the agreement entered into between NHS England and Herts Valleys CCG, which will sit alongside the delegation and terms of reference.

12. It is not within the remit of the committee to consider the commissioning of other primary care services such as community pharmacy, dentistry or optometry. The interface between general practice and other primary care services will be considered by the Commissioning Executive Committee.

13. The functions of the committee are undertaken in the context of a desire to promote increased co-commissioning to increase quality, efficiency, productivity and value for money and to remove administrative barriers.

14. The role of the committee shall be to carry out the functions relating to the commissioning of primary medical services under section 83 of the NHS Act.

15. This includes the following:  GMS and APMS contracts (including the design of APMS contracts, monitoring of contracts, taking contractual action such as issuing breach/remedial notices, and removing a contract);  Newly designed enhanced services (“Local Enhanced Services” and “Directed Enhanced Services”);  Design of local incentive schemes as an alternative to the Quality Outcomes Framework (QOF);  Decision making on whether to establish new GP practices in an area;  Approving practice mergers;  Making decisions on ‘discretionary’ payment (e.g., returner/retainer schemes);and  Enabling and supporting transformational change in primary care medical services. Primary Care Commissioning Committee Terms of Reference v 1.5 August 2020

 Decision making relating to practice premises.

16. The CCG will also carry out the following activities: a) To plan, including needs assessment, primary medical care services in west Hertfordshire; b) To undertake reviews of primary medical care services in west Hertfordshire c) To co-ordinate a common approach to the commissioning of primary care services generally; d) To manage the budget for commissioning of primary medical care services in west Hertfordshire.

Geographical Coverage 17. The committee will comprise the area covered by Herts Valleys CCG.

Membership

18. The Committee shall consist of:

Three CCG Board Lay Members An independent and suitably experienced clinician

A clinical quality representative, being Joint 1Director of Nursing & Quality Joint1 Chief Finance Officer Joint1 Chief Executive Officer Director of Primary Care The CCG Deputy Clinical Chair 2 CCG Board GP Members, with another 2 available as deputies (these four to cover all localities)

The following members can send a deputy to represent them:

Joint Chief Executive Officer – Managing Director Joint Chief Finance Officer- Deputy Chief Finance Officer Joint Director of Nursing and Quality – Deputy Director of Nursing and Quality

19. The Chair of the Committee shall be a CCG Board Lay Member.

20. The Vice Chair of the Committee shall be a CCG Board Lay Member.

1 ‘Joint’ signifies the Joint Executive for HWE ICS and CCGs Primary Care Commissioning Committee Terms of Reference v 1.5 August 2020

21. Regular non-voting attendees of the Committee will be:

 Managing Director  Assistant Director, Localities and General Practice Development.  Assistant Director Premises  One elected representative from the Hertfordshire Health and Wellbeing Board.  One representative from Healthwatch Hertfordshire.  One representative from the Local Medical Committee.  Other members of the HVCCG Primary Care Team.  A patient representative of the Board  Other attendees by invitation as required.

Meetings and Voting

22. The committee will operate in accordance with the CCG’s Standing Orders. The Secretary to the committee will be responsible for giving notice of meetings. This will be accompanied by an agenda and supporting papers and sent to each member representative no later than four working days before the date of the meeting. When the Chair of the committee deems it necessary in light of the urgent circumstances to call a meeting at short notice, the notice period shall be such as s/he shall specify.

23. Each member of the committee shall have one vote. The committee shall reach decisions by a simple majority of members present, but with the Chair having a second and deciding vote, if necessary. However, the aim of the committee will be to achieve consensus decision- making wherever possible.

Quorum

 One Lay member being either Chair or Lay vice Chair  Two executive voting representatives from NHS Herts Valleys CCG listed in paragraph 18 above  One non-conflicted suitably experienced clinician voting member.

Frequency of meetings

24. Meetings will take place approximately bi-monthly

25. Meetings of the committee shall: a) be held in public, subject to the application of 25(b); b) the committee may resolve to exclude the public from a meeting that is open to the public (whether during the whole or part of the proceedings) whenever publicity would be prejudicial to the public interest by reason of the confidential nature of the business to be transacted or for other special reasons stated in the resolution and arising from the nature of that business or of the proceedings or for any other reason permitted by

Primary Care Commissioning Committee Terms of Reference v 1.5 August 2020

the Public Bodies (Admission to Meetings) Act 1960 as amended or succeeded from time to time.

26. Members of the committee have a collective responsibility for the operation of the committee. They will participate in discussion, review evidence and provide objective expert input to the best of their knowledge and ability, and endeavor to reach a collective view.

27. The committee may delegate tasks to such individuals, sub-committees or individual members as it shall see fit, provided that any such delegations are consistent with the parties’ relevant governance arrangements, are recorded in a scheme of delegation, are governed by terms of reference as appropriate and reflect appropriate arrangements for the management of conflicts of interest.

28. The committee may call additional experts to attend meetings on an ad hoc basis to inform discussions. 29. Members of the committee shall respect confidentiality requirements as set out in the CCG’s Constitution and standards of business conduct policy.

30. The committee will present its minutes to central midlands area team of NHS England and the governing body of Herts Valleys CCG every two months for information.

31. The CCG will also comply with any reporting requirements set out in its constitution.

32. It is envisaged that these Terms of Reference will be reviewed from time to time, reflecting experience of the committee in fulfilling its functions. NHS England may also issue revised model terms of reference from time to time.

Accountability of the committee For the avoidance of doubt, in the event of any conflict between the terms of the Delegation and Terms of Reference and the Standing Orders or Standing Financial Instructions of any of the members, the Delegation will prevail.

Decisions

33. The committee will make decisions in line with the CCG’s standing financial instructions.

34. The decisions of the committee shall be binding on NHS England and Herts Valleys CCG.

Conflicts of interest

35. Herts Valleys CCG takes seriously its statutory duties to manage conflicts of interest. It also recognises that there are specific risks of conflicts of interest relating to primary care commissioning, as local GPs are involved in decision making. These risks are mitigated in a Primary Care Commissioning Committee Terms of Reference v 1.5 August 2020

number of ways, including: 36. The committee is constituted to have a lay and executive majority. This ensures that committee meetings are quorate if all local GPs had to withdraw from the decision-making process due to conflicts of interest. 37. The committee has a lay chair and lay vice chair. 38. Standing invitations are made to the CCG’s local Healthwatch Hertfordshire representative, a local authority representative from the local Health and Wellbeing Board and the central midlands area team. 39. Maintaining declarations of interest register for the committee. 40. Capturing declarations of interest in respect of the agenda items both prior to and at the commencement of each meeting. 41. Holding committee meetings in public, unless it would be prejudicial to the public interest by reason of the confidential nature of the business to be transacted

Reporting

42. The committee will produce an executive summary report which will be presented to central midlands local team of NHS England and the board of Herts Valleys CCG every two months for information. 43. The committee will receive reports and minutes from its working groups. All papers will state whether or not a working group has been consulted.

Review

44. The committee will make an assessment of its effectiveness at least once every 12 months. 45. Terms of Reference for the committee will be reviewed at least every 12 months

Review of these Terms of Reference delayed due to the Covid19 pandemic necessitating the cancellation of committees from February to May 2020.

Terms of Reference v 1.5 approved by the Primary Care Commissioning Committee on 20 August 2020

Ratified by the CCG board on 24 September 2020

Date of next review August 2021

Primary Care Commissioning Committee Terms of Reference v 1.5 August 2020

Schedule 1 – Delegation

The CCG and NHS England signed the Delegation Agreement on 16 March 2017. The Agreement became effective on 1 April 2017. The Agreement sets out the arrangements that apply in relation to the exercise of the Delegated Functions by the CCG.

Schedule 2 – Delegated functions

Decisions in relation to the commissioning, procurement and management of Primary Medical Services Contracts, including but not limited to the following activities:

 decisions in relation to Enhanced Services;  decisions in relation to Local Incentive Schemes (including the design of such schemes);  decisions in relation to the establishment of new GP practices (including branch surgeries) and closure of GP practices;  decisions about ‘discretionary’ payments;  decisions about commissioning urgent care (including home visits as required) for out of area registered patients;  the approval of practice mergers;  planning primary medical care services in the Area, including carrying out needs assessments;  undertaking reviews of primary medical care services in the Area;  decisions in relation to the management of poorly performing GP practices and including, without limitation, decisions and liaison with the CQC where the CQC has reported non- compliance with standards (but excluding any decisions in relation to the performers list);  management of the Delegated Funds in the Area;  Premises Costs Directions Functions;  co-ordinating a common approach to the commissioning of primary care services with other commissioners in the Area where appropriate; and  such other ancillary activities that are necessary in order to exercise the Delegated Functions.

Primary Care Commissioning Committee Terms of Reference v 1.5 August 2020

Herts Valleys Clinical Commissioning Group Primary Care Commissioning Committee Draft Committee Work Plan and Deadlines for Papers PCCC Parts 1 & 2, 2020/21 (updated 03.11.20) *N.B. Bank holidays affect timescales

Deadlines for Papers (unless alternative 2020 2021 arrangements have been agreed with the Chair and Exec Lead) Date of Meeting 16 April 18 June 20 August 17 September -virtual 19 November 21 January* 18 March Draft Agenda developed 20 March 22 May 24 July 11 August 23 October 11 December 19 February Agenda Approved by Chair 23 March 25 May 27 July 14 August 26 October 14 December 22 February Draft Papers Received 30 March 1 June 3 August 21 August 2 November 21 December 1 March Deadline for Papers Review 3 April 5 June 7 August 4 September 6 November 8 January 5 March Final Papers to be received by 5pm 8 April 10 June 12 August 9 September 11 November 13 January 10 March Final Papers to Committee 9 April 11 June 13 August 10 September 12 November 14 January 11 March Administrative items Committee work plan √ √ √ √ √ √ √ Committee terms of reference √ Committee self-assessment of effectiveness √ Private – papers circulated virtually Flu programme GP Fwd view Session in public 1. Board Assurance Framework and Strategic √ √ √ √ Objectives 2. Primary Care directorate report √ 2.1 GP extended access – progress √ √ √ √ 2.2 Locality transformation plans - progress √ √ √ √ 2.3 Enhanced Commissioning Framework ? √ 3. Finance report √ √ √ √ √ √ 4. HMMC Report √ √ √ √ √ √ 5. MOCL report √ √ √ √ √ √ 6. Flu √ √ update report LT 7. Supporting practices Winter plans √ 8. Audit outcomes √ 9. Deep dives √ √ √ GP Extended Access Review of practice Primary Care Estates 1 year review quality visit programme provision

10. Other ad hoc reporting (if required) Delegated Commissioning MO support in care homes To go virtually before NHSE revised (A) January – PCNs arrangements development funding approach

Committee work plan PCCC 2020/21 v1

NHS Herts Valleys Primary Care (Medical Services) Commissioning Committee meeting on Thursday 19th November 2020

Please refer to further guidance here \\HVCCG-FS01\Shared\Nursing & Quality\8 Risk Management System\2. Board Assurance Framework\BAF 202021\Current versions for front sheet reference when completing this front sheet. Title Primary Care Directorate Report Agenda item 8 NHS Official Sensitive: Commercial ☐ Check the box if paper contains commercial information which may be damaging to the CCG, another NHS body or a commercial partner if improperly accessed. NHS Official Sensitive Personal ☐ Check the box if paper contains personal information relating to an identifiable individual where inappropriate access could have damaging consequences. Purpose (click Decision ☐ Approval ☐ Discussion ☐ Assurance ☒ Information only ☐ appropriate box) Author and job title Responsible director and job title Director signature The director is signing to indicate their approval of the paper and to confirm that any EQIA, QIA or DPIA has been approved. Updates provided by Primary Care Lynn Dalton, ICS/CCGs Director of Primary Directorate Team members Contracting and Commissioning Localities, Primary Care Commissioning and Contracting and Primary Care Transformation Short summary of paper The paper provides assurance of the work programmes as part of the Recovery and Restoration work streams throughout the Primary Care Directorate. A broad selection of updates is included in the report. Covering areas Locality Engagement, developing a communication platform and a risk stratification tool (GEMIMA) Progress reporting on the Enhanced Effective Resource Management (eERM) Programme which has been paused.

Progress on Population Health Management training for the practices, asylum seekers, across West Hertfordshire and the development of Primary Care Networks. As well as updates on Extended Access, GP Enhanced Commissioning Framework (GPECF) Quality and Outcome Framework (QOF) and the impact of Covid -19, NHSE assurance and draft templates.

Recommendation(s) The Committee is being asked to: . Note the report Engagement with patients/public/staff and . PCN Clinical Directors and Managers other stakeholders . Practice Managers via the HVCCG Practice Manager Forum . Primary Care Covid Group (PCCOG) which includes Local Medical Committee (LMC) representation

Transforming Delivery. We will work with health and social care partners to transform the delivery of care ☒ through the implementation of “Your Care, Your Future”, the Strategic Review in west Hertfordshire and its fit with the wider STP strategy, “A Healthier Future”. Affordable & Sustainable Care. We will ensure that we fulfill our statutory duty to deliver a financially ☒ sustainable and affordable healthcare system in west Hertfordshire. Board Assurance Framework Refer to latest BAF report here for current and target risk scores: \\HVCCG-FS01\Shared\Nursing & Quality\8 Risk Management System\2. Board Assurance Framework\BAF 202021\Current versions for front sheet reference Ref. Risk Risk description Current risk Target risk *Assurance Owner score and score Level movement Example: *Refer to assurance levels table below. 1.2 LD / Risk that member practices, local providers, local 12→ 8 Medium AS authorities and other partners do not respond constructively to engagement 2.1 DC Risk that we do not deliver on all NHS Constitutional 16→ 8 Medium pledges, key national targets and priorities

2.5 LD/ Risk that the CCG lacks the capacity and capability to 8→ 4 Medium AS/ET manage business as usual and additional requirements. 3.2b LD Risk that there will be insufficient capacity for GP 12→ 8 Medium practices, primary care networks and federations to deliver the transformation of care in west Hertfordshire. New strategic risks identified by this report None identified Other significant risks related to this report (from the Corporate Risk Register) None identified Resource No financial resources identified in the paper CFO Signature implications

Potential conflicts All HVCCG GP representatives are conflicted as their GP Practices benefit from this of interest Programme and the associated funding.

However, this paper is to update on progress and development only with no requirement for decision making.

Any conflicts of interest will be managed through the normal process within the Primary Care Commissioning Committee. Equality impact EqIA guidance and templates can be found here: assessments https://hertsvalleysccg.nhs.uk/index.php?cID=396&ctask=check- (EqIA) out&ccm_token=1589455256:3e207909b1095fe958b46568d4737914 and Please confirm that the EQIA has been reviewed and approved by Paul Curry, Equality and Diversity ☐ Quality Impact Lead [email protected] Assessments QIA guidance and templates can be found here: (QIA) https://hertsvalleysccg.nhs.uk/index.php?cID=274&ctask=check- out&ccm_token=1589455689:d086eb2b318f0736d4fedaa33780c2ab Please confirm that the QIA has been reviewed and approved by Clare Molloy, Deputy Director ☐ Nursing and Quality [email protected] Attach the approved analyses when submitting your draft and final reports. Decision makers are required to assure themselves that the reasons given for ‘none required’ are adequate.

EqIAs will be Individual EQIAs are completed for each work stream where appropriate. published on the HVCCG website. No negative impacts have been identified.

EqIA attached ☐ Key points: Not required at this meeting QIAs will be reported to the Quality Committee. QIA part 1 attached ☐ Key points: Not required at this meeting

QIA part 2 attached ☐ Key points: Not required at this meeting

Equality delivery Does your paper provide supporting evidence for HVCCG’s EDS2 portfolio? system (EDS2) Please refer to EDS2 guidance here: https://www.england.nhs.uk/wp-content/uploads/2013/11/eds- nov131.pdf and indicate which goal your proposal/paper supports by clicking the appropriate box(es) Better health outcomes ☒ Improved patient access and experience ☒ A representative and supported workforce ☒ Inclusive leadership ☒ Data Protection Complete a DPIA checklist to establish whether one is needed Impact https://hertsvalleysccg.nhs.uk/intranet/ccg-staff/information-governance Assessment Liaise with the Data Protection Officer or Information Governance Manager to complete the necessary (DPIA) form [email protected] or [email protected] Confirm that your DPIA has been reviewed by the Information Governance Lead, approved by the ☐ Information Governance sub-group and is attached to your draft or final report Key outcomes and how they will be implemented: N/A

Report history No report history associated with this paper, however monthly updates will be provided at the Primary Care Working Group.

Following the Primary Care Commissioning Committee, the updates are shared with the HVCCG Patient and Participation committee (for information).

Appendices Appendix 1 Slides presented at Recovery Management Team (RMT) meeting 5th November 2020 to be added

1. Executive Summary

This paper relates to the HVCCG strategic risks on the BAF as noted on the front sheet above. The current assurance levels overall is noted as medium. The Primary Care Commissioning Committee (PCCC) can therefore take some assurance that the controls upon which the organisation relies to manage this risk are suitably designed, consistently applied and effective and actions are undertaken to ensure risks are managed appropriately.

This paper is to provide the Committee assurance of the progress from Primary Care, Contracting and Localities including actions taken to respond to the Covid-19 pandemic.

2. Locality Engagement Portfolio

At the August PCCC, Primary Care and Localities provided an update on the Recovery and Restoration work plan to support the phased return to ‘business as usual’ post Covid. This included

progress on re-establishing Locality meetings including Delivery Board meetings (across all four locality areas).

All four localities have continued with virtual locality meetings through September and October alongside regular catch ups with Locality Chairs (including vice chairs).

Dacorum Locality Forum meetings have continued in September and October to ensure good communication with all of the practices. The practice manager’s meeting took place in September but was cancelled in October due to annual leave and lack of availability due to increasing pressure on practices. The delivery board met again in September and October and has confirmed the structure of the meetings and Board leads for the work streams in the locality transformation plans. The Terms of Reference (TOR) for this meeting was ratified at the September meeting by all members of the Dacorum Board in line with the TOR of the West Hertfordshire Delivery Board (WHDB) and the Integrated Care Partnership ((ICP) objectives.

Hertsmere continues to have monthly virtual locality forums and Locality Delivery Boards virtually, without a compromise to the quality of communication. The Delivery Board has identified priorities for Hertsmere and reviewed and provided feedback on the locality transformation plans. The TOR for this meeting was ratified at the October meeting and the locality transformation plans were signed off. A further meeting held in November served as an introduction to the new clinical transformation lead Mike Walker and further induction meetings are being arranged to confirm work stream leads and next steps.

Hertsmere also have a regular monthly practice managers meeting and the Mental Health Forum met in September and will continue quarterly. Hertsmere PPG have been given the possibility of attending the locality forum and the Delivery Board as virtual meetings of the group have not currently been reinstated.

St Albans and Harpenden have now undertaken two Locality Delivery Board meetings in September and October. Through these meetings, it has been identified that key priorities will be identification of Carers, Frailty (Falls) and Social Prescribing and Deprivation. At the October meeting, break-out sessions were undertaken (through the virtual platform) and provided a key area from the Locality Transformation Plan to focus on any issues and identify if any pathways may/may not be working.

A Slido session took place where member of board could directly feed into. Terms of Reference is yet to be fully signed off, this requires to allocation of particular areas/workstreams to be allocated to system wide partners including voting rights. In particular, the vice chair for St Albans and Harpenden is assigned to the eERM programme and Population Health Management (PHM).

In addition, the LCC meetings, which was previously undertaken nine times per year will now take place on a quarterly basis (next meeting is scheduled for January 2021).

Watford and Three Rivers have undertaken two Locality Delivery Board meetings in September and October. Through these meetings, it has been identified that key priorities will be a focus on prevention, emotional resilience, self-care, physical activity, population health. Terms of Reference have been signed off but it has been agreed that the board continue to develop the membership list.

In addition, the LMG meetings have been reviewed and through consultation with the GP and Practice Manager membership that it has been agreed to reduce the monthly meetings to bi- monthly.

3 Clarity TeamNet (Communication digital platform)

With the Locality Team taking on the lead role of managing the GP Daily Comms process (originally undertaken through the Comms Team), this has involved all communication being streamlined though to a central Primary Care Comms inbox, each update/and or communication is reviewed for submission within the overall daily GP Comms or being sent as an ‘standalone’ option.

Clarity TeamNet is a platform where additions such as communication updates will be uploaded directly, allowing the practices to view updates as and when. Practices will be notified by an ‘alert email’ when anything has been uploaded (this will include training updates). In addition, HVCCG has purchased Clarity TeamNet for licences for three years which will allow the practices to benefit from this purchase as well, as they will not need to purchase licences until 1st April 2023 if it was still deemed an appropriate platform.

While some GP Practices already use this platform (for GP appraisals/training updates) the team have been have been working with the IT Team to ensure that practices are signed-up to use Clarity TeamNet and have at a minimum of one ‘superuser’ per practice.

To date, 47 out of 55 GP Practices have registered with Clarity TeamNet. We are planning to roll-out the Clarity TeamNet across the locality with a start date of 7th December 2020. To ensure that the process is working well and that GP Practices are accessing Clarity TeamNet, it is envisaged that a ‘dual’ run approach will take place for an additional two weeks. Once this has been successfully rolled out in full to GP Practices, Primary Care Networks will have the opportunity to register.

4 Risk Stratification Tool –GEMIMA

At the August PCCC, Primary Care and Localities provided an over view of the Arden & Greater East Midlands (AGEM) risk stratification report which had been added to the GEMIMA Business Intelligence (BI) tool and the Clinical Super Users Group (CSUG) that was established to provide clinical guidance to commissioners on how the risk stratification tool should be applied in support of practices and the various programmes of work within the CCG and the wider system.

The CSUG continues to seek consensus on specific cohorts for inclusion in the eERM objectives to be reviewed by each practice using the risk stratification tool. The clinicians involved in the CSUG have always emphasised the importance of the CCG being clear and specific about cohorts that practices should review as part of the eERM. The group received feedback on a cohort of patients evaluated by Dr Hannah O’Keeffe (Hertsmere ERM Lead) combining cohorts who are at high risk, and where there is an existing community service that can provide an effective intervention and a cohort informed by evidence of good results from other parts of the NHS (from AGEM clinical lead). The group did not conclude with a consensus that these groups were the right ones to follow up and concerns were raised about capacity in primary care at this time and whether they would be able to devote much energy on additional preventative care. However the proposal for each practice to review five HIU patients per month was accepted.

The risk stratification group will now submit its proposals to the CCG and ask for consideration on how the use of the risk stratification tool should be further utilised in primary care.

5 Enhanced Effective Resource Management (eERM)

The eERM Meeting on the 5th November 2020 was the first meeting following the pause due to Covid-19, future meetings will be coordinated on a bi-monthly basis. The meeting invited the attendance of representatives across all localities and relevant representatives from all of our

partners, including acute and community providers. The group was asked to focus on the revised objectives. The group considered the situation as it is now; particularly in relevance to increased pressure on primary care due to flu vaccinations and possible COVID vaccination campaigns. Consideration was given to what would need to be implemented to meet the revised objectives of the scheme.

All at the meeting were aware of the pressure on all providers currently and agreed that further demands on primary care and healthcare providers at this current time would not be realistic.

Hertfordshire Partnership Foundation Trust expressed an interest to be involved and will work together with the HVCCG Team to ensure that their interventions and those of the HIU Community Navigators can support primary care in reviewing HIUs.

It was however agreed that locality level data should be continued to be shared on a monthly basis at the Locality Delivery Board meetings so as clinical leads are made aware of the trends and the variations between practices and PCNs. An updated proposal will be presented to the West Herts Delivery Board in December and a further eERM meeting will be arrange for January 2021 to review the situation and decide on next steps.

6 Population Health Management (PHM)

Population Health Management (PHM) training has been delivered in three of the four localities. The St Albans & Harpenden training has been arranged in November. The Primary Care Networks PCNs have been provided with an overview of PHM and presented with data packs specific to their PCNS, so as they can identify areas of priority. The areas identified so far have included End of Life, Care Homes and Cancer Prevention. PCNs will be provided with further support to identify their priority areas and develop PHM action plans at PCN level. Arden and Gem have also been invited to the Locality Delivery Boards to present the data to all of our partners and providers and to discuss how these potential priorities and plans will align with the locality transformation plans.

7 Support for Asylum Seeks in West Hertfordshire

Due to the COVID-19 response, all the initial accommodation centers (IAC) for Asylum Seekers are full due to lack of dispersal by the Home office and as a result a significant number of Asylum Seekers have been dispersed to contingency accommodation based in hotels. As a result of this and the anticipated lack of movement of Asylum Seekers at this time, CCGs with IACs in their areas have been required by NHS England to provide a primary medical care service to support the Asylum Seekers.

Herts Valleys CCG (HVCCG) have two IAC hotels in our area, the Watermill Hotel in Hemel Hempstead (74 maximum beds) and the Elstree Inn in Borehamwood (maximum 40 beds). As such, we are required to provide enhanced, essential and additional primary medical care services to Asylum Seekers who due to the Home Office COVID-19 response are currently residing at both hotels.

Parkwood Surgery has been providing the care for the service users in the hotels for the last 5 months. The residents from the Watermill hotel are being dispersed to accommodation in various places around the country and it will be empty by the end of October. Parkwood Surgery has been given a months’ notice until the end of November.

Evaluation of the service has shown that the residents in Elstree Inn hotel have not utilised the services as much as the Watermill residents because of the distance to the surgery. We therefore sought a new practice based in Borehamwood to provide this service. Based on the location of Fairbrook Medical Centre and the vicinity to Elstree Inn it has been decided to ask Fairbrook Medical Centre to provide the enhanced service.

Along with the approach taken in West Essex CCG, we are now considering re-registering all residents as permanent patients to ensure patient safety, safe referral to community and secondary care and onward transfer of their medical records.

8 Primary Care Network (PCN) DES

There were a number of Key Milestones in the PCN Network DES that PCNs were required to complete by 31st October. A drop in session took place on 17th September where these were discussed and highlighted; a DES assurance document was circulated to the CDs detailing all requirements and suggested actions that needed to be taken

8.1 Additional Roles Reimbursement Scheme (ARRS)

PCNs were required to submit their additional roles reimbursement scheme (ARRS) Workforce planning template giving indicative workforce plans through to 2024 by 31st October. Two new roles- Associate Nurse and trainee Associate Nurse have been introduced and we have worked with PCN Clinical Directors to ensure that they plan to utilise the funding which is available to them. Following a review, the CCG submitted the aggregated plan to NHSE on 9th November and will discuss with PCN Clinical Directors plans on how to commit any planned underspend, at the planned PCN development session on 11th November.

8.2 Enhanced Health in Care Homes (EHCH)

HVCCG has now completed the process of aligning all care homes, including Learning Disability homes to a single PCN.

An options paper was presented to the Committee virtually in October which detailed 3 options for consideration for the delivery of the EHCH specification. The Committee were in favour of the 3rd option which is in line with East and North Herts CCG model and meets the requirements of the MDT approach. PCNs will provide all aspects of the Care Home specification at the enhanced rate of £207.87 per bed. Work is underway to support PCNs to mobilise this model by 1st December 2020.

8.3 Early Cancer Diagnosis

PCN CDs were invited to attend a webinar held by Cancer research UK to offer support and resources available for them; 14 PCN’s attended and the webinar was circulated to all PCNs for review. The CCG Cancer leads have also set up a drop in share and learn session in November supported by Cancer research UK.

8.4 Clinical Directors OD Programme

As part of the restoration and recovery work the PCN Clinical Directors OD programme was reinstated and adapted to virtual delivery.

To condense the programme into meaningful sessions, the Kings fund were appointed to combine the identified requirements of the plan, and they have created a bespoke 6 model programme, over a six-month period, which is available to all PCN Clinical Directors, their successors or any aspiring PCN leaders. In addition to this a number of stand-alone sessions were commissioned, including Equality and Diversity, Chairing meetings and the NHS Leadership academy 360 feedback processes

As part of the development programme Arden and Gem were commissioned to provide training in Population Health Management (PHM), and will be providing ongoing support to PCNs in the development of their PHM plans which will identify any health inequalities and priorities in the PCN population together with action plans to address them.

Numbers of candidates participating in the sessions has been lower than anticipated; however, some changes to timings and dates to enable better attendance have been made, and a plan is being developed to gather feedback for Clinical Directors as to why this is. It is likely that the current climate is having an adverse effect on the time available to Clinical Directors.

The training and development co-ordinator has now been appointed who with gather feedback from the PCN Clinical Directors and will work with them to promote the programme to show how the leadership dimensions relate to PCNs. Results of the 360 feedback process will continue to facilitate the ongoing delivery of the programme and support future training to ensure all commissioned development programmes are tailored to meet the needs.

9 GP Extended Access

During the first peak of Covid-19, Extended Access services used clinical time and resources to support the local NHS provider and wider system. Return to usual services took place during June and from July – September 2020, appointment utilisation of Extended Access services across the CCG was over 90%.

The majority of appointments continue to take place via telephone or online consultation with some face to face appointments. Where telephone appointments continue, the provider has scheduled face to face appointments to follow up with patients if necessary.

The contract review meetings had been suspended in March due to Covid and were resumed in September 2020.

Extended Access will go into the PCN DES from 2020/21 and the CCG will be working jointly with the PCNs and the current providers to ensure that this is a smooth transition. The CCG are waiting further guidance from the national team regarding this and will be available to advise all parties once this has been received.

9.1 GP Connect

Following enablement of GP Connect for direct booking into practices, to date a total of 4,235 appointments have been directly booked since April. The highest number at a single practice is 386 appointments booked, and the average across the CCG is 83 appointments.

To date there are still four practice settings where there has been no appointment made and the CCG’s IT facilitators are investigating the reasons behind this jointly with NHS Digital, Directory of Service leads, and Herts Urgent Care colleagues.

In addition, there are nine settings where there have been fewer than 20 appointments booked. Again in this instance the CCG team are investigating any issues with NHS Digital and urgent care colleagues.

There have been delays with implementing direct booking to extended access as it was discovered there were configuration issues with Extended Access provider clinical systems. These have been resolved in conjunction with NHS Digital colleagues, and the first test is due to take place in Extended Access settings w/c 9 November 2020. Further testing will take place with other providers once the initial test has taken place and any learning implemented.

Once complete and implemented this will ensure that 111 providers will be able to book directly into practice and into embargoed Extended Access appointments.

10 GP Enhanced Commissioning Framework (GPECF)

A paper regarding the restart of the GPECF programme was circulated to the committee virtually for approval in October. The committee requested that this be reviewed in light of LMC comments and a refreshed restart document was submitted, and is in the process of being approved.

However, in light of pressures general practice are facing due to the extended Flu Programme, winter pressures and the recently announced mass Covid vaccination programme, CCGs across the ICS are reviewing their local services to determine where services may be impacted or could be stopped if non-essential. The CCG are considering flexing the “best endeavours” approach to the GPECF and ensuring that practices will not be financially impacted because of these pressures. A further meeting with ICS colleagues is due to take place and further communications will be issued to practices following this.

11 Quality and Outcomes Framework (QOF) 2020/21

COVID-19 has had a disproportionate impact upon some of the most vulnerable patients both directly due to the effects of the disease and indirectly due to the impact upon service delivery and economic impact. Therefore, NHS England have revised their approach to QOF in 2020/21 and this aims to release capacity within general practice to focus efforts upon the identification and prioritisation of people at risk of poor health and those who experience health inequalities for proactive review including:

. Those most vulnerable to harm from COVID-19; evidence suggests that this includes patients from BAME groups and those from the 20% most deprived neighbourhoods nationally (LSOAs) . Those at risk of harm from poorly controlled long-term condition parameters; and, . Those with a history of missing annual reviews.

The CCG has developed a template which has been discussed with CCG Board GPs, LMC and members of the Primary Care Working Group. This template is a simple, high-level template which will act as the practices QOF Prioritisation Plan as required under the “Protected Income Points” for the QOF changes for the remainder of the year. This has been circulated to practices who have been asked to sign and return a declaration form to the CCG which will act as confirmation they have completed the form and will be implementing this.

Practices are asked to also confirm they have an agreed plan with their commissioner as part of the e-DEC self-declaration return due by end of November and therefore. We have aligned our approach across the ICS.

12 Restoration and Recovery

During October 2020, an NHSE GP Metrics template spreadsheet was circulated to all practices across the ICS. The GP Metrics template sought assurance across six key areas for General Practice, Access, patient reviews and health checks, cancer, immunisations, prioritising care and data quality. For some of the areas specific timelines have been given. (Table 1)

Table 1

Area Assurance required Access Practices offering a total triage model. Offering telephone, consultations, online appointments, video consultations, face to face appointments, where clinically appropriate. Offering the requirement amount of appointment slots for NHS111 Direct Booking (1 slot for each 500 registered patients) Patient reviews and By 30th September 2020, all practices to have re-established the health checks following services; Clinical reviews of frailty New patient reviews Over 75s health checks Routine medication reviews Learning Disabilities health checks Cancer By 30th September 2020. Practices offering sufficient cervical screening appointments to meet the demand of prior notification slots (prior notification lists sent by the cervical screening administration service in advance of patient invitations) Immunisations By 30th September 2020. Practices have invited for immunisations all children that have missed any routine under 5s immunisations Practices re-established the routine call for shingles vaccinations Prioritising care By October/November 2020 Practices to have an agreed patient prioritisation plan with the CCG for the following patients 1. Those at greatest risk of harm from Covid-19 2. Uncontrolled long term conditions parameters 3. Those with a history of missing reviews

Data Quality By 31st December 2020 Practices have commenced a proactive data review to ensure completeness of patient ethnicity data

Please see Appendix 1 slides that were presented at the Recovery Management Team meeting on 5th November 2020. The slides demonstrate RAG ratings across the six areas at an ICS level.

GP Metrics 1- Access

Appendix 1 provides a slide on Accessing Primary Care Services – HVCCG National data. The data reports on appointments made across the following areas; video/online, unknown, telephone, home visits and face to face appointments. When reviewing the slide in appendix 1, it shows that face to face appointments have increased 137% overall between, April 2020-September 2020, just slightly dipping in the month of August.

The overall appointments for September 2020 was 222,342 and compared to September 2019 226,629, it is hopefully demonstrating that access to GP services is starting to get back to pre-Covid activity. October’s data will be published the end of November, with November’s data coming in at the end of December. It will only be at that point when the November data has been released that we will start to see the impact of ‘lockdown’ (5th November -2nd December 2020), if any.

Healthwatch recently published their report in October 2020 which covered areas across primary care, secondary care, mental health services and adult care services. Surveys were conducted from 11th May -31st July. Section 6 of Healthwatch’s report focussed on GP Access. Surveys were conducted across all practices in Hertfordshire but do not distinguish whether the findings are from HVCCG practices or E&NH CCG practices.

Some comments taken from the report ‘The majority of respondents said their GP practice did not use remote consultations prior to Covid- 19’ ‘The majority of respondents had said it had been a positive experience when they contacted their GP practice for an appointment. In some cases, some patients said they received a better service compared to usual, primarily because the GP practice was able to respond quicker than usual and schedule an appointment with a short time frame.

Other benefits reported were elimination of travel and time waiting in the waiting rooms.

There was mixed messages about communication regarding practices not being closed. Some said they had received very good communication. Whilst others reported very poor communication but again difficult to determine which practices these were, due to not being able to determine the individual practices across Hertfordshire.

GP Metrics Red, Amber, Green (RAG) ratings across the ICS (Appendix 1)

HVCCG is green for Access (GP Metrics 1), Cancer (cervical screening appointments) GP Metrics 3 and Immunisations (GP Metrics 4) Amber areas include Patient Reviews and Health Checks (GP Metrics 2) and Data Quality (GP Metrics 6).

Where HVCCG is amber against the five areas in the patient reviews and health checks, practices are being contacted to understand the barriers for them to fully re-establish these services. For example practices may not be able to carry out clinical reviews of frailty if their clinical staff are self-isolating due to Covid-19 related absences. Practices may also have to prioritise care within the practice for their patients, for example ensuring that all of their eligible groups for the flu vaccination have

attended for their vaccinations, or having to go into a care home at different stages, due to a Covid outbreak impacting on when the flu vaccines can be administered to the care home residents.

For the Data Quality, the CCG will continue to monitor the practices progress and will offer support as the practices still have until the end of December 2020 to review their patient ethnicity data

GP Metrics 5: Prioritising Care, covered in section 11 of this report, 2020/21 Quality Outcomes Framework (QOF)

13 – NHSE Key Lines of Enquires (KLOEs) Appendix 1

During October, NHSE also released another template document in draft but confirmed the areas specified in the document was not to be submitted as a situation return (sit rep) Instead the document was to be used as an assurance template checklist across the system making sure everything was in place in the event of a Covid-19 Wave 2.0 occurring. Primary Care teams across the ICS will be going through the draft template individually as CCGs.

However HVCCG’s Assistant Director of Primary Care and Localities meets with E&NH CCG and West Essex on a weekly basis, ensuring that discussions will focus on the checklist, aligning and sharing best practice across the ICS as well as reviewing processes implemented in wave 1.0 to establish whether or not they are appropriate for wave 2.0 or will need further revising or adjustments.

The areas in the draft template cover three broad areas, governance, managing demand and safe and effective care.

Appendix 1:- Slide deck presented to the Recovery Management Team 5th November 2020

NHS Herts Valleys Primary Care Commissioning Committee 17 November 2020

Short summary of paper This paper provides assurance of how general practice is being supported with workforce development, education events, clinical pharmacy and practice nurse forums.

The paper also provides assurance of the collaborative working that is taking place across the Herts and West Essex ICS. Recommendation(s) The report is for information

Engagement with N/A patients/public/staff and other stakeholders Links to Strategic Objectives (click on all boxes that apply) Effective Engagement. We will continually improve engagements with member practices, patients, the public, ☒ carers and our staff to contribute to and influence the work of Herts Valleys CCG. Quality. We will commission safe, good quality services that meet the needs of the population, reducing ☐ health inequalities and supporting local people to avoid ill health and stay well. Transforming Delivery. We will work with health and social care partners to transform the delivery of care ☒ through the implementation of “Your Care, Your Future”, the Strategic Review in west Hertfordshire and its fit with the wider STP strategy, “A Healthier Future”. Affordable & Sustainable Care. We will ensure that we fulfill our statutory duty to deliver a financially ☒ sustainable and affordable healthcare system in west Hertfordshire. Board Assurance Framework Refer to latest BAF report here for current and target risk scores: \\HVCCG-FS01\Shared\Nursing & Quality\8 Risk Management System\2. Board Assurance Framework\BAF 202021\Current versions for front sheet reference Ref. Risk Risk description Current risk Target risk *Assurance Owner score and score Level movement *Refer to assurance levels table below. 1.2 LD / Risk that member practices, local providers, local 12→ 8 Medium AS authorities and other partners do not respond constructively to engagement 2.1 DC Risk that we do not deliver on all NHS Constitutional 16→ 8 Medium pledges, key national targets and priorities

G1 HVCCG Front Sheet May 2020 v3.0

Other significant risks related to this report (from the Corporate Risk Register)

Resource State funding costs and potential saving. This should include non-financial CFO Signature implications resources. Any proposals for investment must be signed off by the Chief N/A Finance Officer (CFO). The signature is confirmation that the CFO has read the proposal but does not mean that funding will be released.

Potential conflicts State how any conflicts of interest have been managed. of interest Are there any interests that the meeting chair should be made aware of in relation to this paper? If yes, state name of person conflicted and nature of the interest. Equality impact EqIA guidance and templates can be found here: assessments https://hertsvalleysccg.nhs.uk/index.php?cID=396&ctask=check- (EqIA) out&ccm_token=1589455256:3e207909b1095fe958b46568d4737914 and Please confirm that the EQIA has been reviewed and approved by Paul Curry, Equality and Diversity ☐ Quality Impact Lead [email protected] Assessments QIA guidance and templates can be found here: (QIA) https://hertsvalleysccg.nhs.uk/index.php?cID=274&ctask=check- out&ccm_token=1589455689:d086eb2b318f0736d4fedaa33780c2ab Please confirm that the QIA has been reviewed and approved by Clare Molloy, Deputy Director ☐ Nursing and Quality [email protected] Attach the approved analyses when submitting your draft and final reports. Decision makers are required to assure themselves that the reasons given for ‘none required’ are adequate. EqIAs will be Indicate below the attachments accompanying your report and the key points the analysis has published on the HVCCG website. identified, relevant to the decision required: EqIA attached ☐ Key points: QIAs will be reported to the QIA part 1 attached ☐ Key points: Quality Committee.

QIA part 2 attached ☐ Key points:

Equality delivery Does your paper provide supporting evidence for HVCCG’s EDS2 portfolio? system (EDS2) Please refer to EDS2 guidance here: https://www.england.nhs.uk/wp-content/uploads/2013/11/eds- nov131.pdf and indicate which goal your proposal/paper supports by clicking the appropriate box(es) Better health outcomes ☐ Improved patient access and experience ☐ A representative and supported workforce ☒ Inclusive leadership ☐ Data Protection Complete a DPIA checklist to establish whether one is needed Impact https://hertsvalleysccg.nhs.uk/intranet/ccg-staff/information-governance Assessment Liaise with the Data Protection Officer or Information Governance Manager to complete the necessary (DPIA) form [email protected] or [email protected] Confirm that your DPIA has been reviewed by the Information Governance Lead, approved by the ☐ Information Governance sub-group and is attached to your draft or final report Key outcomes and how they will be implemented:

G1 HVCCG Front Sheet May 2020 v3.0

Report history none

Appendices Appendix 1 Primary Care Workforce Development local training hub team structure

1. Executive Summary

This paper is to provide the Committee assurance of the work that is taking place to support Herts Valleys Primary Care Workforce development and work taking place to deliver the Hertfordshire and West Essex ICS Training Hubs workforce plan.

The current assurance levels overall is noted as medium, suggesting the Committee can take some assurance that the controls in which Herts and West Essex ICS have in place are consistently applied and effective and actions are undertaken to ensure risks are managed appropriately. This paper is to provide the Committee assurance of the progress of the workforce workstreams.

2. GP Retention Programme 2.1 Virtual Primary Care Educational Sessions – All Health Care Professionals A series of educational sessions for all Primary Care health care professionals has been organised to provide an opportunity for health care professionals to develop their knowledge further. The sessions have been led by Dr Nicolas Small.

The first session took place in July 2020; the topic was Wellbeing, presented by Dr Richard Pile. Since July five other sessions have taken place covering colorectal cancer, diabetes, MSK and dermatology. The next session will take place on 3 December 2020 and the topic will be ‘The role of the Physician Associate in Primary Care’.

Sessions take place throughout the lunch period as this is the preference for the current speakers. The plan is to include some evening sessions. Sessions are recorded and the link is circulated widely to allow those who missed the session to access.

2.2 Celebrating Primary Care Workforce Innovations and Successes Event The celebrating primary care workforce innovations and successes event took place on 21 October 2020. The event was opened by Dr Jane Halpin, Joint Chief Executive Officer, Herts & West Essex ICS & CCGs. Dr Elizabeth Eyitayo presented the individual and team awards; John Wigley and Jill Ainsworth presented the special recognition awards; Dr Nicolas Small did a tribute to the Practice Manager Hilary Mills-Williams who had recently passed away and a recognition of the outstanding work that had taken place in primary care during covid and David Evans, Managing Director, Herts Valleys CCG closed the event. Over 98 people joined the event.

The aim of the event was to recognise Practices and their workforce who strive to make an exceptional contribution to Primary Care and to share good practice.

The event has received very positive feedback and demonstrated the commitment and hard work of the Primary Care workforce across Herts Valleys area that has taken place throughout covid.

A combination of individuals and team nominations were received - in total twenty-six.

The categories for the individual nominations were: 1. Working above and beyond 2. Making a difference 3. Team Spirit 4. Outstanding innovator

G1 HVCCG Front Sheet May 2020 v3.0

The individual nominations had five winners in total as there was a draw on the working above and beyond category.

The categories for the team nominations were: 1. Supported retention and recruitment of staff 2. Reduced GP Workload 3. Introduced new roles 4. Combination of categories

Two special recognition awards were given to Dr Mike Walton and Dr Daniel Carlton-Conway for being an inspiration to all in primary care as they have both worked above and beyond since covid hit.

The judges had an unbelievably difficult job in deciding on the winners as so much good work had taken place across primary care during covid. Each and every person who was nominated had shown their commitment and dedication to primary care.

The individual winners all received a £25 gift voucher to be spent towards helping to shape and support their health and wellbeing. The team winners received a £100 gift voucher to be spent on an item of choice for their Practice, PCN or Federation towards supporting their health and wellbeing in the workplace.

The event was recorded and a link will be circulated to all practices to circulate and will be available to access on the Herts Valleys website along with the names of all who were nominated and the winners.

2.3 Backfill funding for GP Career Development for mid-career/experienced GPs To support GP retention up to £12,600 has been allocated from Hertfordshire and West Essex ICS to cover backfill costs for a GP who wants to work within Herts Valleys CCG for one session a week for one year. The roles that were available were:  Cancer Health Prevention Lead  Primary Care Workforce Development – Supporting PCN Workforce Development

Dr Ketan Bhatt was recruited to the role of GP Primary Care Workforce Development – Supporting PCN Workforce Development. Dr Bhatt will start in the role on 12 November 2020.

Interest in the Cancer Health Prevention Lead role has been disappointing. The advert was circulated a number of times. One application has been received. It is hoped that recruitment will take place by December 2020.

2.4 Clinical Lead – Primary Care Workforce for GPs Dr Jayna Gadawala took up post on 5 November 2020 on a 12 month fixed term contract as the Clinical lead for leading the delivery of work that supports primary care workforce development for GPs. Dr Gadawala will be part of the Primary Care Workforce Development, local training hub team and will manage a team of GPs (See attached team structure – appendix 1).

2.5 ST4 GP Fellow Dr Joshua Stranders joined the Primary Care Workforce Development, local training hub team in October 2020 on a 12 month placement to support his development in workforce. He is working on developing some support for Clinical Pharmacists in primary care.

3. Clinical Pharmacists – Networking and Peer Support Sessions The clinical pharmacist networking and peer support sessions are taking place monthly and being led by Leen Kubba the Primary Care Clinical Pharmacist Tutor. Recent session topics have been ‘Delivering Medicines Optimisation in Care Homes’ and ‘an overview of a mental health medication

G1 HVCCG Front Sheet May 2020 v3.0 review’. Sessions have been well attended and feedback from the sessions is positive. The sessions consist of a series of presentations followed by group discussions.

4. General Practice Nursing 4.1 Promoting General Practice Nursing as a first destination career The Primary Care Practice Nurse Tutors (Diane Springall and Lyn Murphy) have been working with schools and colleges to deliver virtual presentations to students to promote general practice nursing as a first destination career. The tutors are working with West Herts and Oakland colleges, Marlborough Academy, St Albans and Laureate Academy, Hemel Hempstead.

Future school presentations will include the wider team ie Primary Care Clinical Pharmacist tutor and a GP to provide an introduction to the other roles within primary care that students may be interested in.

4.2 Practice Nurse/Health Care Assistant Forums Practice Nurse and Health Care Assistant forums take place twice monthly across the Herts Valleys area facilitated by the primary care nurse tutors. The forums consist of a series of presentations followed by group discussions. Recent topics have been Cancer care update, diabetes, stroke prevention, meeting health needs and annual health checks for patients on the learning disability register during covid 19, and safeguarding training. Sessions are well attended and feedback from the sessions is positive.

4.3 Clinical Supervision for Practice Nurses The primary care nurse tutors are offering small groups of nurses the opportunity to meet and learn from each other and gain some support and advice about their role. Sessions take place monthly across the localities.

5. Training and Development for Practice Staff 5.1 Funding Herts Valleys CCG Primary Care Workforce Development local training hub and Herts and West Essex ICS Training hub have funded a variety of training and development opportunities for the Primary Care workforce. Information about funded courses is regularly circulated to Practices.

The table below demonstrates training that has been funded by Herts Valleys CCG Local training hub since September 2020: -

Course Number of booked

Advanced Management (Practice Managers) 13

Cervical Screening 2 Ear Care Workshop 1 Fundamentals of Childhood Immunisations 1 Providing good clinical supervision 6 Further Medical Terminology 30 Communications, Customer Service and dealing 24 with challenging behaviours in GP Practice Communications, Customer Service and dealing 15 booked with challenging behaviours in GP Practice Course taking place 17 Nov 2020 Leading your team 13 Effective Medical Chaperoning 15 booked Course taking place 2 December 2020 Understanding blood tests 15 booked Course taking place 20 January 2021

G1 HVCCG Front Sheet May 2020 v3.0

5.2 Supporting Career Development in Primary Care All staff in the Herts Valleys CCG local training hub team support/signpost and provide guidance to primary care staff about education and training options that will support their career development plan.

Contact details of the primary care workforce development team can be found on the Herts Valleys CCG intranet.

5.3 £1,000 CPD funding for Practice Nurses and Allied Health Professionals Earlier this year it was announced that all General Practice Nurses and Allied Health Professionals in Primary Care would receive £1,000 for continuing professional development (CPD) over the next 3 years with a third (£333) being provided in each year.

On 14 July 2020 all PCNs and Practices were contacted by Herts & West Essex ICS Training Hub via clinical directors and informed of the funding and asked to provide information regarding the training requirements for their staff. The information provided was submitted to Health Education England via the Herts and West Essex ICS Training hub. HEE approved the funding.

Herts and West Essex ICS have tasked the local CCG Training hubs with the operational management of the funding. Local CCG training hubs will report monthly to Herts and West Essex ICS Training hub of funding spent todate. Herts Valleys CCGs allocation is £31,478. Herts and West Essex ICS training hub will be responsible for reporting the total spend across the ICS to HEE on a monthly basis.

On 27 October 2020 all Herts Valleys Practices were informed of the personal training budget and given a process to follow to enable them to access the funds.

This offer is a great opportunity for Practices to be able to develop their workforce further.

5.4 Apprentice Nursing Associate Discussions have been taking place with Health Education England, Herts and West Essex student nursing associate manager and Herts and West Essex ICS Training hub Lead Nurse to establish funding to support Practices to recruit to the apprenticeship nursing associate programme.

Local CCG workforce leads will check that applicants are eligible for the programme and if not provide support to get them into a position to be able to apply. Herts and West Essex ICS Training hub will confirm funding when applicant is ready to make their application to the University. Funding will be gifted by Herts and West Essex ICS levy.

Currently funding has been agreed for one HCA to undertake the apprentice nursing associate programme starting January 2021.

Herts Valleys has six other HCAs who have expressed an interest in the course. Work is currently taking place to check their eligibility to access the programme.

The closing date for the January 2021 intake is 23 November 2020. The course will not run again until September 2021.

6. Physician Associates (PA) Herts Valleys/East and North Herts/West Essex CCG Primary Care Workforce Development local training hubs, Herts and West Essex ICS training hub and Emma Day, Physician Associate Ambassador for Health Education England are having conversations with Hertfordshire University to open up discussions with general practices about Physician Associate placements. Herts University currently have 35 new students in year one and 35 students in their second year.

G1 HVCCG Front Sheet May 2020 v3.0

The group are looking at what is needed to support both Practices and the university in finding suitable placements for the current cohort of PAs.

The next meeting will take place on 11 November 2020.

7. Herts and West Essex ICS Primary Care Workforce Website Herts and West Essex ICS training hub launched the primary care workforce website in September 2020. The site provides lots of information about training and development opportunities, news and events and much more. The website has a link to the local CCG training hubs websites so that primary care staff can obtain information about their local workforce leads and opportunities. The link to the website is below: https://www.hwetraininghub.org.uk/

The link has been circulated to all Herts Valleys Practices.

8. Summary The PCCC are asked to note the content of this paper and the work that is taking place across Herts Valleys and the Herts and West Essex ICS. The PCCC can be assured that progress is being made in line with NHSE and HEE requirements. A range of primary care attraction and retention work streams have been developed and these continue to be actively promoted.

G1 HVCCG Front Sheet May 2020 v3.0

NHS Herts Valleys Primary Care (Medical Services) Commissioning Committee meeting on Thursday 19th November 2020

Short summary of paper This paper describes the approach in which the CCG would like to devolve the national PCN Development Funding allocation to PCNs on a capitation basis for 2020/21. There are clear principles in which this funding can be used which are outlined in the paper and the governance process which is being suggested will provide assurance to the PCCC and NHSE/I that the funding has been utilised in the appropriate way.

In 2019/20, the CCG worked with the PCN Clinical Directors to develop a full OD Programme using this allocation with an additional CCG investment as top-up. Due to the Covid pandemic, extended flu programme and now the mass vaccination programme in which primary care will play a key role in delivering; PCNs need the flexibility to decide how best to utilise their Development Funding allocation in the most appropriate way to support their PCN strategy, workforce recruitment and development and integration with other community providers; rather than have a rigid framework in which they need to work within.

This approach aligns with the approach taken across East and North Herts CCG so that there is a consistent approach across Hertfordshire. Recommendation(s) The Committee is being asked to: Note the content of the paper and approve:  The devolution of the funding down to PCN on a weighted capitation basis  Agree the governance process in which to provide assurance on the utilisation of this funding at PCN level Engagement with The approach was discussed with the PCN Clinical Directors at a PCN session on 11 patients/public/staff and November 2020 and all were supportive of this approach. other stakeholders

Affordable & Sustainable Care. We will ensure that we fulfill our statutory duty to deliver a financially ☒ sustainable and affordable healthcare system in west Hertfordshire. Board Assurance Framework Refer to latest BAF report here for current and target risk scores: \\HVCCG-FS01\Shared\Nursing & Quality\8 Risk Management System\2. Board Assurance Framework\BAF 202021\Current versions for front sheet reference Ref. Risk Risk description Current risk Target risk *Assurance Owner score and score Level movement Example: *Refer to assurance levels table below. 1.2 LD / Risk that member practices, local providers, local 12→ 8 Medium AS authorities and other partners do not respond constructively to engagement 2.5 LD/ Risk that the CCG lacks the capacity and capability to 8→ 4 Medium AS/ET manage business as usual and additional requirements. 3.2b LD Risk that there will be insufficient capacity for GP 12→ 8 Medium practices, primary care networks and federations to deliver the transformation of care in west Hertfordshire. New strategic risks identified by this report None identified Other significant risks related to this report (from the Corporate Risk Register) None identified Resource CFO Signature implications The national allocation for Herts Valleys CCG is £452,157

Potential conflicts All HVCCG GP representatives are conflicted as their GP Practices are part of a Primary Care of interest Network which will benefit from this funding. It is also noted that one GP member of the Committee is also a PCN Clinical Director.

QIAs will be QIA part 1 attached ☒ Key points: Not required at this meeting reported to the Quality Committee. QIA part 2 attached ☐ Key points: Not required at this meeting

Report history N/A

Appendices

1. Executive Summary

This paper is to provide the Committee with the intended approach on the devolution of the national PCN Development Funding

2. Background

In 2019/20 NHSE provided national funding to support PCN Development in the GP Forward View funding allocations to CCG. The funding was to be used for two purposes:

 Primary Care development  Specific Clinical Director development programme in each STP/ICS. The funds are intended to help PCNs make early progress against their objectives – for example supporting much closer practical collaboration between PCNs and their community partners, including preparatory activity for the forthcoming national service specifications.

The CCG provided extensive support both in management time and financial support to PCNs in the run up to the implementation of the PCN DES to ensure that they were prepared and ready to deliver the DES services as required. It was recognised, through the completion of the PCN Maturity Matrix, that further support was needed to develop the leadership skills of the Clinical Director and Management Leads.

In December 2019, the Primary Care Commissioning Committee approved the proposal presented in which the CCG would use the GPFV funding allocations of £438K alongside an additional investment of £33,760 to delivery an Organisational Development Programme specifically for Clinical Directors, plus an identified successor and the PCN Management Leads. The funding was also used to support the training and implementation of the Population Health Management Programme; both of these programmes were suspended due to Covid but have now re-commenced as part of the CCG’s Primary Care Recovery Workplan.

3. 2020/21 PCN Development Funding Allocation

The PCN Development Funding for 2020/21 has now been identified and NHSE/I have confirmed that the funding should be deployed in accordance with the following key objectives, as a minimum:

 To support recruitment, embedding and retention of new staff, helping to build capacity and address high workload, as well as supporting full spend of ARRS funding. Staff will be supported to have the skills and capability to operate effectively across networks and as part of integrated teams. Staff induction, clinical supervision and a focus on staff wellbeing and resilience, along with support to model demand and re-design ways of working should help embed the new workforce

 To enhance integration by building on the work that’s already happened with care homes, community services teams and community pharmacy in response to Covid-19 and strengthening this through multi-disciplinary team ways of working with other local providers. Working with patients, their carers’ and the wider community will be essential to create a joint model of proactive and personalised care.

 To continue to improve access by embedding the use of total triage and remote consultation; cutting waiting times and supporting the interface between primary, community and secondary care.

 To reduce health inequalities, enhancing population health management locally with a focus on prevention, recognising the inequality in relation to COVID-19 and those groups who may have been disproportionally disadvantaged.

NHSE/I also confirmed that ICSs are responsible for PCN development and the delivery of priorities set out for 20/21 and are expected to engage and work closely with PCN Clinical Directors to come to collective agreement on local priorities and how funding should consequently be spent to respond to their specific need. This will include agreement on whether support is secured at place or system level (to gain econcomies of scale) and agreement of the governance required to ensure PCN priorities set out for 20/21 are delivered.

Examples of specific spend may include support to drive quality improvement, change management support, staff wellbeing and resilience interventions or support to develop leadership skills across PCNs as set out in the 19/20 PCN development support guidance.

NHSE/I Regions will ensure that systems use the funding in line with the priorities set out and according to the following parameters:

 A universal offer, with PCN clinical and non-clinical staff receiving support matched to their needs  Support designed alongside and agreed with PCNs and CDs, promoting collaboration and shared understanding within PCNs and with wider partners, and recognising that commissioning some elements of support, once, at the system or place level is likely to make sense  Alignment with commitments set out in the NHS Long Term Plan and the Network Contract Direct Enhanced Service (DES), and supporting delivery of system strategies  The NHSE/I national team will work with regional teams over the next few months to determine how to evidence PCN development progress. This is likely to include focussing on the agreed priorities (as set out above) and discussion about the outcomes we would like PCNs to achieve over the next 3-4 years, giving due consideration to independent evaluation.

The 3 CCGs across the Herts and West Essex ICS regularly meet and have discussed aligning our approach on the use of the PCN Development Funding and therefore the proposal in Herts Valleys is to distribute the CCGs allocation across all 17 PCNs on a weighted capitation basis with an appropriate governance process in place to provide the assurance to the Primary Care Commissioning Committee, Governing Body and to NHSE/I that the Development Funding is being utilised in an appropriate way and in line with the national objectives.

This approach allows the PCNs to apply flexibility to direct the funding to where it is most needed.

Examples of expected utilisation may include:

 Support for PCNs to develop & implement key PHM initiatives  Clinical leadership/supervision to support recruitment, development & management of ARR scheme staff  Support for reconfiguration of service delivery to maximise & embed new ARR scheme roles  Support PCNs with the wider integration agenda, including further development of multi- disciplinary team working

The proposed CCG specific governance requirements are outlined below:

 PCNs will be required to provide plans for 20/21, including indicative spend, to enable the CCG to release funding; these plans should clearly demonstrate the key objectives in accordance with the development priorities for 20/21.  An end of year report of spend/planned spend is required per PCN. Funding is contingent on PCN reporting which confirms spending in accordance with these parameters.  Any commissioned training/development costing over £1,000 per course/session requires prior approval from the CCG. Details should be provided to the CCG using a CCG PCN Development Fund application template (to be developed). Spend under £1,000 does not require prior approval.  PCNs should proceed in utilising this funding ensuring value for money, obtaining more than one quotation as appropriate  Any single project costing over £5,000 would require prior approval of the CCG (it should be noted the funding to support a single project is for planning and implementation only and not for the delivery of services or other operating costs)  Any proposals involving planned spending on technology/equipment would require prior CCG approval.  This funding can be used for backfilling clinical time to support engagement in PCN transformation activities, up to a maximum of 50% of the available funding. PCN proposals that exceed this will require prior approval by the CCG.  Reimbursement will be made in accordance with CCG defined hourly reimbursement rates.

4. Funding Allocation

The 20/21 PCN Development Funding allocation for Herts Valleys is £452,157 and the breakdown for each PCN, based on 1 January 2020 weighted capitation is detailed in the table below:

PCN Development PCN Weighted List Sizes Funding PCN as of 1st January 2020 Allocation 20/21 ALPHA 51,560 £ 38,192 BETA 37,736 £ 27,952 DELTA 33,506 £ 24,819 DANAIS 29,078 £ 21,539 POTTERS BAR 29,917 £ 22,160 HERTS FIVE 65,550 £ 48,554 ABBEY HEALTH 24,539 £ 18,177 ALBAN HEALTH 41,172 £ 30,497 HARPENDEN HEALTH 37,405 £ 27,707 HLH PCN 35,529 £ 26,317 ATTENBOROUGH PCN 35,673 £ 26,424 CENTRAL WATFORD 31,265 £ 23,159 THE GRAND UNION 51,723 £ 38,313 MANOR VIEW PATHFINDER 30,497 £ 22,590 NORTH WATFORD 25,389 £ 18,806 THE RICKMANSWORTH & CHORLEYWOOD 27,174 £ 20,128 ALLIANCE PCN 22,713 £ 16,824 610,425 £ 452,157

If the recommendations are approved it is proposed that no funding will be released to PCNs until the indicative spend and plan is received and approved by the CCG. Due to the timing of the release of funding, it would be expected that PCNs will be required to submit their end of year report by 30 November 2021. (Acknowledging that further Development Funding may be provided in 21/22 and will be subject to further approval by this Committee).

5. Recommendation

The Committee is asked to consider the points in the paper and approve the following recommendations:

a) Approve the distribution of PCN development funding to each PCN on a capitation basis as per the table in section 4. b) Approve the governance process in which the CCG will implement to provide assurance on the planned expenditure to meet the national objectives.

NHS Herts Valleys Primary Care (Medical Services) Commissioning Committee meeting on Thursday 19th November 2020

Please refer to further guidance here \\HVCCG-FS01\Shared\Nursing & Quality\8 Risk Management System\2. Board Assurance Framework\BAF 202021\Current versions for front sheet reference when completing this front sheet. Title Flu Update Agenda item 11 NHS Official Sensitive: Commercial ☐ Check the box if paper contains commercial information which may be damaging to the CCG, another NHS body or a commercial partner if improperly accessed. NHS Official Sensitive Personal ☐ Check the box if paper contains personal information relating to an identifiable individual where inappropriate access could have damaging consequences. Purpose (click Decision ☐ Approval ☐ Discussion ☐ Assurance ☒ Information only ☐ appropriate box) Author and job title Responsible director and job title Director signature The director is signing to indicate their approval of the paper and to confirm that any EQIA, QIA or DPIA has been approved. Lynn Talbot, Project Manager Lynn Dalton, Director of Primary Care

Short summary of paper This paper is to provide the Committee assurance of progress of the seasonal flu programme, particularly in the context of the Covid pandemic.

Recommendation(s) The Committee is being asked to: ▪ Note the report Engagement with patients/public/staff and ▪ PCN Clinical Directors and Managers other stakeholders ▪ PCN Flu Project Managers ▪ HVCCG Task and Finish Group ▪ Practice Managers via the HVCCG Practice Manager Forum

1.2 LD / Risk that member practices, local providers, local 12→ 8 Medium DE authorities and other partners do not respond constructively to engagement 2.1 DC Risk that we do not deliver on all NHS Constitutional 16→ 8 Medium pledges, key national targets and priorities

2.5 LD/ Risk that the CCG lacks the capacity and capability to 8↑ 4 Medium AS/ET manage business as usual and additional requirements. 3.2b LD Risk that there will be insufficient support from GP 12→ 8 Medium practices and GP federations to transform the delivery of care in west Hertfordshire. New strategic risks identified by this report None identified Other significant risks related to this report (from the Corporate Risk Register) None identified Resource No financial resources identified in the paper CFO Signature implications

Potential conflicts All HVCCG GP representatives are conflicted as their GP Practices benefit from this of interest Programme and the associated funding.

However, this paper is to update on progress and development only with no requirement for decision making.

Any conflicts of interest will be managed through the normal process within the Primary Care Commissioning Committee.

Equality impact EqIA guidance and templates can be found here: assessments https://hertsvalleysccg.nhs.uk/index.php?cID=396&ctask=check- (EqIA) out&ccm_token=1589455256:3e207909b1095fe958b46568d4737914 and Please confirm that the EQIA has been reviewed and approved by Paul Curry, Equality and Diversity ☐ Quality Impact Lead [email protected] Assessments QIA guidance and templates can be found here: (QIA) https://hertsvalleysccg.nhs.uk/index.php?cID=274&ctask=check- out&ccm_token=1589455689:d086eb2b318f0736d4fedaa33780c2ab Please confirm that the QIA has been reviewed and approved by Clare Molloy, Deputy Director ☐ Nursing and Quality [email protected] Attach the approved analyses when submitting your draft and final reports. Decision makers are required to assure themselves that the reasons given for ‘none required’ are adequate. EqIAs will be Individual EQIAs are completed for each work stream where appropriate. published on the HVCCG website. No negative impacts have been identified. EqIA attached ☐ Key points: QIAs will be reported to the Quality Committee. QIA part 1 attached ☐ Key points:

QIA part 2 attached ☐ Key points:

Inclusive leadership ☒ Data Protection Complete a DPIA checklist to establish whether one is needed Impact https://hertsvalleysccg.nhs.uk/intranet/ccg-staff/information-governance Assessment Liaise with the Data Protection Officer or Information Governance Manager to complete the necessary (DPIA) form [email protected] or [email protected] Confirm that your DPIA has been reviewed by the Information Governance Lead, approved by the ☐ Information Governance sub-group and is attached to your draft or final report Key outcomes and how they will be implemented: N/A

Report history No report history associated with this paper, however monthly updates will be provided at the Primary Care Working Group.. Following the Primary Care Commissioning Committee, the updates are shared with HVCCG Patient and Participation committee (for information).

Appendices Appendix 1 Primary Care COVID-19 Outbreak Action Card Appendix 2 Free Primary Care Educational Webinar flyer

1. Executive Summary

Considering the risk of flu and COVID-19 co-circulating this winter, the national flu vaccination programme is absolutely essential to protecting vulnerable people and supporting the resilience of the health and care system.

This year the flu vaccination programme is even more challenging than ever working within the context of providing clinics within Infection Prevention and Control (IPC) guidelines, possible greater demand, and practices moving into recovery phase, catching up on work that has been on hold for the last few months.

This paper is to provide the Committee assurance of progress of the seasonal flu programme, particularly in the context of the Covid pandemic.

2. Introduction

This year, because of Covid 19 the flu vaccine is being offered to the additional cohorts (Department of Health and Social Care/Public Health England August 2020):

▪ Household contacts of those on the NHS Shielded Patient List. Specifically, individuals who expect to share living accommodation with a shielded person on most days over the winter and therefore for whom continuing close contact is unavoidable. ▪ children of school Year 7 age in secondary schools (those aged 11 on 31 August 2020). The School Age Immunization Service (SAIS) will be delivering these vaccines. ▪ health and social care workers employed through Direct Payment (personal budgets) and/or Personal Health Budgets, such as Personal Assistants, to deliver domiciliary care to patients and service users The aim is to achieve 75% uptake across all cohorts of patients eligible for the flu vaccine before the end of November.

An additional cohort of adults 50-64 years will be eligible from the end of November, depending on the supply of vaccine.

3. Support and Monitoring

To manage these ambitious targets, we have set up a monitoring system within the CCG and across the ICS. HVCCG have also invested funding in supporting PCNs to deliver the vaccinations including funding for a flu project manager. The project managers meet with the HVCCG weekly to review progress, escalate issues and share learning and these are proving valuable to all who attend. Regular Flu updates are circulated to provide important information.

Flu uptake is also monitored through the ICS, Regional Public Health meeting and NHSE Regional Group.

4. Uptake

Vaccination is well underway and is largely where we would expect to be at this time and our achievement in the most recent data is the highest across the ICS – see Appendix 1. Uptake is above last year’s achievement to date for all indicators, and October trigger points have been met for over-65s. Performance for the under 65 at-risk cohort is a key focus where a national data issue has artificially reduced reported uptake. This is now being addressed through EMIS and as a CCG we are focusing on the correct coding to ensure practices performance data matches the effort they are all putting in. There is a national coding issue affecting the weekly ImmForm vaccine uptake reports. The issue artificially inflates the at-risk denominator thereby hampering efforts to oversee performance. The monthly data will see an improved code-set used; however inaccurate weekly monitoring will continue.

The scarcity of vaccines for the under 65s has also hindered progress. Although ordering guidance for the DHSC procured additional flu vaccination supply has now been made available, practices have reported high levels of vaccine uptake, and many have already exhausted their own supply. Until additional deliveries from the national supply reach providers, providers cannot plan to meet the demand, and risks some patients disengaging with the programme. Deliveries are expected from mid-November.

HVCCG is doing well vaccinating pregnant women even though it not evident in the data. Communication problems with WHHT are being addressed and this should be demonstrated in the data soon as WHHT have vaccinated more than 400 pregnant women. Community midwives from the Royal Free are unable to give vaccinations in GP clinics due to lack of PGDs. Commissioners have raised this with the provider, and we are waiting for feedback.

The School Immunisation Services team are vaccinating year 7s this year in addition to the usual cohorts. The Schools programme is well ahead of previous years due to earlier supplies of vaccine this year, although most schools will require additional visits due to the impact of reduced attendance and bubbles isolating. Additional community catch-up is also being undertaken.

We have encouraged PCNs to vaccinate residents in care and nursing homes as a priority particularly as the Covid vaccine may be available soon and there needs to be a time lapse between the flu vaccine and first Covid vaccination. People with Learning Disabilities have also taken a high priority. Practices have been supported with materials to help

4 communicate and manage the interaction with this cohort of patients. We are making progress with vaccination in care homes although care homes where there are patients with Covid has slowed progress. Practices are being encouraged to wear the correct PPE and vaccinate residents even if there is a Covid positive patient in the home. We are monitoring uptake at CGG level and the national team have commissioned an update to the established Care Home Capacity Tracker reporting tool to provide weekly vaccination uptake data for staff and residents. This is now live and initial reporting now coming through.

Funding to support communications for patients has been provided to ensure that the public understand that primary care is open for flu vaccination. The national advertising campaign has also restarted in support of this. In HVCCG we are targeting communications at parents to encourage them to bring their children for a flu vaccine. In addition, we are encouraging parents to bring children for MMR vaccinations as the National Team are concerned that the reducing uptake may lead to a measles outbreak.

At the beginning of the seasonal flu programme it was announced that 50-64 years olds would be able to obtain a free vaccine. Due to the shortage of vaccines practices have been told not to prioritise this cohort (unless they are eligible in another group) until new guidance is issued at the beginning of November. These patients have been proving difficult to manage as they make demands on practices and pharmacists for their vaccinations. To date, no guidance has been issued and it remains to be seen whether the whole of the 50-64 year cohort will be given flu vaccinations when PCNs and practices are being asked to gear up for the mass Covid vaccination programme.

As rates of Covid-19 increase providers of flu vaccination are likely to come under increased pressure due to the impact of staff sickness and self-isolation. Access to Covid testing and receipt of timely results for healthcare workers will be key, and the rollout of swabbing facilities in general practice will support this.

Appendix 1

At risk 6 months to 2 years

75%

22.2% 11.4% 11.1%

Herts Valleys CCG East & North Herts West Essex CCG CCG

At risk 2-5 year olds

75%

46.7% 37.6% 32.3%

Herts Valleys CCG West Essex CCG East & North Herts CCG

At risk 5-16 year olds

75%

23.5% 22.8% 13.2%

Herts Valleys CCG West Essex CCG East & North Herts CCG

At risk 16-65 year olds

75%

37.0% 31.7% 29.5%

Herts Valleys CCG East & North Herts West Essex CCG CCG

Over 65s

75% 71.9% 70.1% 66.8%

Herts Valleys CCG East & North Herts West Essex CCG CCG

All Pregnant Women

75%

34.7% 27.2% 25.6%

East & North Herts West Essex CCG Herts Valleys CCG CCG

NHS Herts Valleys Clinical Commissioning Group Primary Care Commissioning Committee Meeting 17th November 2020

Please refer to further guidance here \\HVCCG-FS01\Shared\Nursing & Quality\8 Risk Management System\2. Board Assurance Framework\BAF 202021\Current versions for front sheet reference when completing this front sheet. Title Month 6 Finance Report Agenda item 11 NHS Official Sensitive: Commercial ☐ Check the box if paper contains commercial information which may be damaging to the CCG, another NHS body or a commercial partner if improperly accessed. NHS Official Sensitive Personal ☐ Check the box if paper contains personal information relating to an identifiable individual where inappropriate access could have damaging consequences. Purpose (click Decision ☐ Approval ☐ Discussion ☐ Assurance ☒ Information only ☒ appropriate box) Author and job title Responsible director and job title Director signature The director is signing to indicate their approval of the paper and to confirm that any EQIA, QIA or DPIA has been approved. Nicola Peters Elke Taylor Head of Finance Deputy Chief Finance Officer

Short summary of paper This report details the financial performance of the CCG at month 6, September 2020. The report details performance against all the CCG’s key financial duties.

At the end of September 2020, the CCG is forecasting a deficit of £1.054m. Key drivers for this are:  Costs of the response to the pandemic, including Hospital Discharge Programme  Overspends on Prescribing and Other Programme  Offset by the duplication of the MH budget.

A retrospective adjustment to the CCG’s allocation will be made to bring all service lines to breakeven.

There are no unmitigated risks against that position that have been identified to date. The CCG has been prudent in its assessment on areas where judgements apply, such as estimates for accruals.

Recommendation(s) The Board/Committee is being asked to: Note the financial performance year to date and resultant outturn Engagement with State briefly any engagement activities and the relevant outcomes of that engagement. patients/public/staff and other stakeholders Links to Strategic Objectives (click on all boxes that apply) Effective Engagement. We will continually improve engagements with member practices, patients, the public, ☐ carers and our staff to contribute to and influence the work of Herts Valleys CCG. Quality. We will commission safe, good quality services that meet the needs of the population, reducing ☒ health inequalities and supporting local people to avoid ill health and stay well. Transforming Delivery. We will work with health and social care partners to transform the delivery of care ☐ through the implementation of “Your Care, Your Future”, the Strategic Review in west Hertfordshire and its fit with the wider STP strategy, “A Healthier Future”. Affordable & Sustainable Care. We will ensure that we fulfill our statutory duty to deliver a financially ☒ sustainable and affordable healthcare system in west Hertfordshire. Board Assurance Framework

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Refer to latest BAF report here for current and target risk scores: \\HVCCG-FS01\Shared\Nursing & Quality\8 Risk Management System\2. Board Assurance Framework\BAF 202021\Current versions for front sheet reference Ref. Risk Risk description Current risk Target risk *Assurance Owner score and score Level movement

4.1 AP Risk that we do not deliver a financially sustainable integrated healthcare system in 20 5 Medium collaboration with our partners in the STP. (March 2025) 4.3 AP Risk that we do not achieve financial balance in 2020/21 12 4 Low 4.4 AP Risk that we do not have sufficient financial resource to manage the increase in legal 8 8 Medium challenges to our commissioning decisions.

New strategic risks identified by this report

Other significant risks related to this report (from the Corporate Risk Register)

Resource N/A – Information only CFO Signature implications

Potential conflicts None of interest Equality impact EqIA guidance and templates can be found here: assessments https://hertsvalleysccg.nhs.uk/index.php?cID=396&ctask=check- (EqIA) out&ccm_token=1589455256:3e207909b1095fe958b46568d4737914 and Please confirm that the EQIA has been reviewed and approved by Paul Curry, Equality and Diversity ☐ Quality Impact Lead [email protected] Assessments QIA guidance and templates can be found here: (QIA) https://hertsvalleysccg.nhs.uk/index.php?cID=274&ctask=check- out&ccm_token=1589455689:d086eb2b318f0736d4fedaa33780c2ab Please confirm that the QIA has been reviewed and approved by Clare Molloy, Deputy Director ☐ Nursing and Quality [email protected] Attach the approved analyses when submitting your draft and final reports. Decision makers are required to assure themselves that the reasons given for ‘none required’ are adequate. EqIAs will be Indicate below the attachments accompanying your report and the key points the analysis has published on the identified, relevant to the decision required: HVCCG website. EqIA attached ☐ Key points: N/A QIAs will be reported to the QIA part 1 attached ☐ Key points: N/A Quality Committee.

QIA part 2 attached ☐ Key points: N/A

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A representative and supported workforce ☐ Inclusive leadership ☐ Data Protection Complete a DPIA checklist to establish whether one is needed Impact https://hertsvalleysccg.nhs.uk/intranet/ccg-staff/information-governance Assessment Liaise with the Data Protection Officer or Information Governance Manager to complete the necessary (DPIA) form [email protected] or [email protected] Confirm that your DPIA has been reviewed by the Information Governance Lead, approved by the ☐ Information Governance sub-group and is attached to your draft or final report Key outcomes and how they will be implemented: N/A

Report history

Appendices Month 6 Finance Report

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Finance Report Month 6 – September 2020

Elke Taylor – Deputy Chief Finance Officer

Produced by: Nicola Peters – Head of Finance

1 Contents Slide ref Key Headlines 3 Summary Financial Performance by Service Line 4 Acute Commissioning 5 Non-Acute Commissioning 6 - 7 Primary Care Commissioning 8 - 10 Other Programme Costs 11

2 Key Headlines

Financial Regime for Months 1-6 2020/21 Financial Performance for the month ending 30 September 2020 As a result of the COVID-19 pandemic, NHS England (NHSE) has In month 6 the CCG reported a deficit of £1.054m. instigated a financial regime for Commissioners and Providers for The deficit on programme budgets was £0.747m due, primarily, to two Months 1 to 6 2020/21 to ensure financial viability for the NHS factors: during the Crisis Management period. Details of the regime are: • The duplication of the budget for the main provider of Mental Health • Commissioners have been issued with Months 1-6 budget and Services in the acute commissioning budget, equivalent to £6.7m. expected expenditure plans • Offset by in month expenditure of £5.662m relating to Covid-19 • NHSE has issued commissioners with mandated block payments response. for NHS providers with expected expenditure levels of more than Other variances include overspends in: £0.25m • Other Programme, relating to the NHSE budget being insufficient to • ‘Covid’ expenditure is reported within organisations financial meet NHS Property Services 2020/21 cost pressures, reporting, with a coding combination that makes it separably identifiable • Prescribing, where the indicative budget was profiled in 1/12ths. As cumulative variances are adjusted out, any variance in month will • NHSE has issued retrospective adjustments to commissioner lead to an in-month variance. allocations, and provided ‘top-ups’ to NHS providers, to bring all organisations back to breakeven. Non-NHS Community Contracts expenditure is below the NHSE financial envelope due to activity being lower this year compared to 2019/20. As at month 5 the cumulative surplus of £4.816m has been retrospectively adjusted through the CCG’s allocation to bring the The deficit on the Running Cost budget was £308k. The budget set by CCG to a break even position. An underspend of £30.501m, largely NHSE was lower than allocation as the required 20% reduction in due to a mental health budget duplication, has been substantially running costs in 2020/21 had been applied to 2019/20 outturn. offset by overspends in Covid-19 costs, primary care and continuing However, the CCG’s 2019/20 outturn already reflected the lower care. All reported variances for month 6 are therefore those that allocation. Expenditure above the NHSE budget is not a breach of have occurred in month. The CCG’s variance to budget will be business rules, providing spend remains within the CCG’s published retrospectively adjusted in month 7. Running Costs allocation. The CCG expects to receive an allocation adjustment of £1.054m to achieve a breakeven position at the end of month 6, in line with NHSE An update on the financial regime, and associated Plan, for months guidance for the financial regime months 1-6. This will retrospectively 7-12 2020/21 is included within a separate paper to this Committee. set all budget areas to breakeven at the end of month 6.

3 Financial Performance by Service Line

The table below shows the breakdown of the reported surplus by service line. Commentary is on each service line slide and Appendices. YTD MONTH 6

BUDGET AT NON-COVID MONTH 6 VARIANCE 2020/21 Budgets - Source & Application MONTH 6 RELATED COVID COSTS TOTAL favourable / of Funds ACTUALS VARIANCE ACTUALS (adverse) £000 £000 £000 £000 £000 £000

Revenue Resource Limit * 493,468 488,861 4,607 0 493,468 0

APPLICATION OF FUNDS - Programme Acute Commissioning 242,722 236,059 6,663 0 236,059 6,663 Non acute Commissioning: Mental Health 44,371 44,876 (505) 129 45,006 (635) Community 42,884 42,827 57 17 42,845 39 Continuing Care 32,442 32,551 (109) 1,477 34,028 (1,586) Primary care Commissioning: Prescribing 39,351 39,860 (509) 0 39,860 (509) Delegated Primary Care 41,433 41,433 0 0 41,433 0 Enhanced Services 5,019 5,019 (0) 0 5,019 (0) Other Primary Care 10,208 10,435 (227) 339 10,774 (566)

Other Programme Costs 29,787 29,991 (204) 3,698 33,689 (3,902) Total Commissioned Services 488,216 483,052 5,164 5,660 488,712 (496)

Running Costs 5,503 5,809 (306) 1 5,811 (308)

Reserves, Contingency & Provisions: Other Reserves & Provisions (251) 0 (251) 0 0 (251) Total Reserves (251) 0 (251) 0 0 (251)

Total Applications 493,468 488,861 4,607 5,662 494,523 (1,054) In-year Surplus / (deficit) (0) 0 (0) (5,662) (1,055) (1,054) 4 Acute Commissioning

YTD MONTH 6 VARIANCE 2020/21 Acute Commissioning Budgets BUDGET ACTUAL favourable / Application of Funds (adverse) £000 £000 £000

NHS ACUTE PROVIDERS 234,953 234,953 0

HERTS PARTNERSHIP TRUST (MH) 6,706 0 6,706

NCAs 532 557 (25) Multiple providers (IVF) 141 141 0 Individual Funding Request (IFR) 390 409 (19) TOTAL OTHER ACUTE 1,063 1,107 (43)

TOTAL ACUTE COMMISSIONING 242,722 236,059 6,663

The budget shown is the NHSE budget for the block payments to NHS providers, so variances are not expected. However, as mentioned previously, the block payment to HPFT, a Mental Health (MH) provider, has also been included within this service line in addition to the MH service line. Expenditure with this provider is shown within MH. The Other Acute category includes Overseas Visitors, IVF, Individual Funding Requests, and NCA payments to non-NHS organisations.

Non - Acute Commissioning (1)

YTD MONTH 6 NON-COVID VARIANCE BUDGET RELATED COVID COSTS TOTAL favourable / NON ACUTE COMMISSIONING ACTUALS ACTUALS (adverse) £000 £000 £000 £000 £000 Mental Health 44,371 44,841 165 45,006 (635) Community 42,884 42,258 587 42,845 39 Continuing Care 32,442 27,603 6,424 34,028 (1,586) TOTAL NON ACUTE CONTRACTS 119,697 114,702 7,177 121,878 (2,181) Mental Health The CCG is required to meet the Mental Health Investment Standard (MHIS) for 2020/21. This requires investment in MH services, excluding those services for dementia and learning disabilities, at 1.7% more than the published programme growth for 2020/21 of 4.2% i.e. increase investment by 5.9%. The profile of planned investments into MH are weighted towards the latter part of the year. The CCG has planned to meet MHIS in 2020/21. MONTH 5 MONTH 6 MONTH 6 YTD NON-COVID VARIANCE TOTAL BUDGET TOTAL BUDGET RELATED COVID COSTS TOTAL favourable / MENTAL HEALTH BUDGET MOVEMENT BUDGET ACTUALS ACTUALS (adverse) £000 £000 £000 £000 £000 £000 £000 £000 HERTS PARTHERSHIP NHS FT 27,608 6,706 34,314 34,314 34,314 0 34,314 0 MENTAL HEALTH CORE BUDGET 17,019 (6,962) 10,057 10,057 10,527 165 10,692 (635) TOTAL BUDGET AND ACTUALS 44,627 (256) 44,371 44,371 44,841 165 45,006 (635)

6 Non - Acute Commissioning (2)

Community Services NHSE budgets were set by extrapolating and uplifting month 11 2019/20 reported values, and at that point many of the Community Services contracts were over-performing. 2020/21 budgets therefore assume a level of overperformance that is currently not happening. The volume of activity and financial envelopes for these contracts have been agreed with providers i n line with national guidance. Recovery and reinstatement of services is likely to increase costs in the second half of the year.

NON-COVID VARIANCE BUDGET RELATED COVID COSTS TOTAL favourable / COMMUNITY CONTRACTS ACTUALS ACTUALS (adverse) £000 £000 £000 £000 £000 NHS Providers - HCT and CLCH 27,318 27,369 0 27,369 (52) Connect 3,194 1,946 0 1,946 1,247 Community Health & Eyecare Ltd 802 845 0 845 (43) Gynaecology 1,309 1,711 0 1,711 (403) Communitas 790 692 0 692 98 PML 283 242 0 242 42 Health Harmonie 158 32 0 32 126 Millbrook Wheelchairs 889 779 0 779 110 Other Community Contracts 7,958 8,722 587 8,722 (765)

TOTAL COMMUNITY SERVICES 42,884 42,258 587 42,845 39

Continuing Healthcare All patients that are assessed as requiring Continuing Healthcare packages of care on discharge from hospital are currently being reported as part of the Hospital Discharge Programme, irrespective of whether they would normally be funded through social care or required to contribute themselves. The cost of these packages is currently £6.424m. From 1st September, full NHS funding is limited to 6 weeks only. All patients must be assessed for their health and social care needs within that period. A programme to assess all patients currently funded through HDP began on 1st September. 7 Primary Care Commissioning (1)

YTD MONTH 6 NON-COVID VARIANCE BUDGET RELATED COVID COSTS TOTAL favourable / PRIMARY CARE COMMISSIONING ACTUALS ACTUALS (adverse) £000 £000 £000 £000 £000 Prescribing 39,351 39,859 0 39,859 (508) Delegated Primary Care 41,433 41,433 0 41,433 0 Enhanced Services 5,019 5,019 0 5,019 (0) Other Primary Care 10,208 8,016 2,842 10,774 (566) TOTAL PRIMARY CARE 96,011 94,326 2,842 97,085 (1,074)

The Prescribing budget was set by NHSE in equal 1/6ths for month 1-6. The profile for Prescribing being accepted as being variable, and there is usually a ‘national profile’ published, which will allow commissioners to more accurately forecast expenditure. There is currently no published profile for 2020-21 and we are aware that there are pressures on the Prescribing budget from the requirement to prescribe certain anticoagulants (DOACs), NCSO and Category M drugs, certain generic mental health drugs and diabetic medication. The budget is currently being monitored with the PMOT team. Other Primary Care shows an overspend due to Covid expenditure, including that for Hot Hubs. Given the protection of income levels against 2019/20 for Primary Care, Delegated Commissioning and Local Enhanced Services are not showing a variance.

8 Primary Care Commissioning (2)

MONTH 5 MONTH 6 MONTH 6 YTD YTD MONTH 6 ANNUAL FORECAST NON-COVID VARIANCE VARIANCE 2020/21 Primary Care Commissioning TOTAL BUDGET TOTAL BUDGET RELATED COVID COSTS TOTAL favourable / FORECAST favourable / Budgets BUDGET MOVEMENT BUDGET ACTUALS ACTUALS (adverse) (adverse) Application of Funds £000 £000 £000 £000 £000 £000 £000 £000 £000 £000

PRESCRIBING GP Prescribing 36,314 774 37,088 37,088 37,870 0 37,870 (783) 36,314 774 Central Drugs 1,401 0 1,401 1,401 1,216 0 1,216 185 1,401 0 Medicines Management - Clinical 862 0 862 862 773 0 773 89 512 351 TOTAL PRESCRIBING 38,577 774 39,351 39,351 39,859 0 39,859 (508) 38,226 1,125

DELEGATED PRIMARY CARE Clinical&Medical-Clinical Other 0 0 0 0 25 0 25 (25) 0 0 Clinical&Medical-Independent Sector 0 0 0 0 33 0 33 (33) 0 0 DES Extended Hours Access 478 0 478 478 486 0 486 (8) 478 0 DES Learn Dsblty Hlth Chk 125 0 125 125 126 0 126 (1) 125 0 DES Minor Surgery 279 0 279 279 333 0 333 (54) 279 0 Dispensing Quality Sch 11 0 11 11 19 0 19 (9) 11 0 General Practice - APMS 620 0 620 620 591 0 591 29 620 0 General Practice - GMS 26,877 0 26,877 26,877 27,197 0 27,197 (320) 26,877 0 LES Translation Fees 21 0 21 21 21 0 21 0 21 0 MPIG Correction Factor 0 0 0 0 0 0 0 0 0 0 Other Primary Care 899 0 899 899 960 0 960 (60) 899 0 Premises 4,389 0 4,389 4,389 4,307 0 4,307 82 4,389 0 Prescribing / Dispensing Costs 398 0 398 398 398 0 398 (0) 398 0 QOF 4,164 0 4,164 4,164 3,841 0 3,841 322 4,164 0 Recharge 0 0 0 0 0 0 0 0 0 0 Seniority 0 0 0 0 0 0 0 0 0 0 Sterile Products 15 0 15 15 15 0 15 0 15 0 AI-Non Pay General Reserves 0 0 0 0 0 0 0 0 0 0 C&M - Independent Sector - Prior Year 0 0 0 0 0 0 0 0 0 0 DES PCN Support 584 0 584 584 395 0 395 189 584 0 DES PCN Participation 538 0 538 538 529 0 529 8 538 0 DES PCN Clinical Director 238 0 238 238 228 0 228 10 238 0 C&M-GP PRACTICE REVENUE - PCTF 0 0 0 0 (54) 0 (54) 54 0 0 DES PCN Clinical Pharmacist 451 0 451 451 451 0 451 0 451 0 DES Social Prescribing 283 0 283 283 283 0 283 (0) 283 0 DES PCN Invest & Impact 0 0 0 0 135 0 135 (135) 0 0 Programme Support Costs 849 214 1,063 1,063 1,063 0 1,063 0 849 214 DES Physiotherapist 0 0 0 0 45 0 45 (45) 0 0 C&M-PCN DES DIETICIANS 0 0 0 0 4 0 4 (4) 0 0 TOTAL DELEGATED PRIMARY CARE 41,219 214 41,433 41,433 41,433 0 41,433 0 41,219 214

9 Primary Care Commissioning (3)

ENHANCED SERVICES LES Anti-coagulation 183 0 183 183 183 0 183 0 183 0 LES Care Home/Nursing Home 355 0 355 355 355 0 355 0 355 0 LES Care Planning 1,118 0 1,118 1,118 1,118 0 1,118 0 1,118 0 LES Demand Mgmt 0 0 0 0 0 0 0 0 0 0 LES GP Comm Incentive Sch 180 0 180 180 180 0 180 0 180 0 LES Minor Surgery 42 0 42 42 42 0 42 0 42 0 LES Phlebotomy 179 0 179 179 179 0 179 0 179 0 LES Treatment Room 0 0 0 0 0 0 0 0 0 0 Clinical&Medical-Independent Sector 0 0 0 0 0 0 0 (0) 0 0 Clinical&Medical-Clinical Other 6 0 6 6 6 0 6 0 6 0 LES Translation Fees 0 0 0 0 0 0 0 0 0 0 C&M - Independent Sector - Prior Year 0 0 0 0 0 0 0 0 0 0 LES Haematology 0 0 0 0 0 0 0 0 0 0 LES Equitable Funding 1,859 0 1,859 1,859 1,859 0 1,859 0 1,859 0 LES FLU 20 0 20 20 20 0 20 0 20 0 DES PCN Support 1,076 0 1,076 1,076 1,076 0 1,076 0 1,076 0 DES PCN Invest & Impact 0 0 0 0 0 0 0 0 0 0 LES Palliative Care 0 0 0 0 0 0 0 (0) 0 0 LES Gynaecology 0 0 0 0 0 0 0 0 0 TOTAL ENHANCED SERVICES 5,019 0 5,019 5,019 5,019 0 5,019 (0) 5,019 0

OTHER PRIMARY CARE Commissioning Schemes (1) 0 (1) (1) (1) 2,842 2,757 (2,758) 2,184 (2,185) Out of Hours 4,303 0 4,303 4,303 4,303 0 4,303 0 4,303 0 Oxygen 298 0 298 298 274 0 274 24 298 0 Primary Care Investments 2,448 (280) 2,168 2,168 0 0 0 2,168 0 2,168 Primary Care IT 1,132 0 1,132 1,132 1,132 0 1,132 (0) 1,132 0 GP Forward View 2,308 0 2,308 2,308 2,308 0 2,308 0 2,308 0 Primary Care Development 0 0 0 0 (0) 0 (0) 0 0 0 TOTAL OTHER PRIMARY CARE 10,488 (280) 10,208 10,208 8,016 2,842 10,774 (566) 10,225 (17)

TOTAL PRIMARY CARE COMMISSIONING 95,303 708 96,011 96,011 94,326 2,842 97,085 (1,074) 94,690 1,321

10 Other Programme Costs

YTD MONTH 6 NON-COVID VARIANCE BUDGET RELATED COVID COSTS TOTAL favourable / OTHER PROGRAMME COSTS ACTUALS ACTUALS (adverse) £000 £000 £000 £000 £000 Better Care Fund 6,100 6,269 0 6,269 (170) Patient Transport 1,768 1,828 360 2,188 (420) Non Recurrent Programme 1,570 1,568 0 1,568 1 Other 20,349 2,709 20,954 23,663 (3,314) TOTAL OTHER PROGRAMME 29,787 12,375 21,313 33,689 (3,902)

Other Programme Costs are reporting a Year-to-Date overspend of £3.902m. This is primarily due to costs incurred through the Hospital Discharge Programme (HDP). The HDP spend in month 6 was £3.687m. Of the total reported cost to date of the HDP of £21.239m, £11.993m relates to beds for East and North Herts CCG, with the remainder for Herts Valleys patients. Additional Patient Transport costs of £0.056m have been incurred in month 6 due to the requirements under the Hospital Discharge Programme that all patients are transported within 2 hours of being declared ready for discharge. This has required the commissioning of additional crews to support discharge and allow deep-cleaning of vehicles. Full breakdowns of Covid-19 costs and Hospital Discharge Programme costs are included as Appendix 1 & 2.

NHS Herts Valleys Clinical Commissioning Group Primary (Medical) Care Commissioning Committee Meeting th Date of Meeting: 19 November 2020

Please refer to further guidance here \\HVCCG-FS01\Shared\Nursing & Quality\8 Risk Management System\2. Board Assurance Framework\BAF 202021\Current versions for front sheet reference when completing this front sheet. Title Pharmacy and Medicines Optimisation Team Summary Report – October 2020 Agenda item 12 NHS Official Sensitive: Commercial ☐ Check the box if paper contains commercial information which may be damaging to the CCG, another NHS body or a commercial partner if improperly accessed. NHS Official Sensitive Personal ☐ Check the box if paper contains personal information relating to an identifiable individual where inappropriate access could have damaging consequences. Purpose (click Decision ☐ Approval ☐ Discussion ☐ Assurance ☒ Information only ☐ appropriate box) Author and job title Responsible director and job title Director signature The director is signing to indicate their approval of the paper and to confirm that any EQIA, QIA or DPIA has been approved. Janet Weir, Senior Pharmaceutical Advisor Rachel Joyce, Director of Clinical and Professional Services Short summary of paper This paper outlines the: 1. Herts Valleys CCG Medicines Optimisation Clinical Leads (MOCL) group summary – Oct 2020 2. Hertfordshire Medicines Management Committee (HMMC) summary –Oct 2020 a. Recommendations of HMMC on treatments that are not subject to NICE guidance. b. Mandatory NICE Technology Appraisals (TAs) published 24th June 2020 – 7th October 2020 with the financial implications for noting. c. MHRA drug safety updates June to Sept 2020. Recommendation(s) The Board/Committee is being asked to: 1. Ratify the recommendations reached by MOCL. 2. Ratify the recommendations reached by HMMC on treatments that are not subject to NICE TAs; note the NICE TAs published and likely impact of these on the commissioner’s budget; note national directives/initiatives that will impact on medicines optimisation.

NICE technical appraisals (TAs) are national guidance and Herts Valleys CCG is legally obliged to fund and resource medicines and treatments recommended by these TAs. They are presented to the Primary Care Commissioning Committee for information and to note the likely impact on the commissioner’s budget.

Recommendations reached by HMMC and MOCL are negotiated with a committee of clinicians, with particular focus on evidence base, cost and patient safety. HMMC and MOCL recommendations are presented to the Primary Care Commissioning Committee for ratification, although decisions with no negative financial impacts made at MOCL may be implemented prior to PCCC approval.

Engagement with The MOCL group includes as members Medicines Optimisation Clinical Leads from patients/public/staff and each of the four Herts Valleys CCG Localities, a GP Board member, representation other stakeholders from the Herts Valleys CCG Pharmacy and Medicines Optimisation Team, representation from Hertfordshire LPC and two patient representatives.

The HMMC group includes as members all stakeholders with whom both Herts

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Valleys CCG and East and North Herts CCG have direct contracts, two patient representatives, representation from the Bedfordshire and Hertfordshire Local Medical Committee (LMC) and the Hertfordshire Local Pharmaceutical Committee (LPC), GP Board members from each CCG and one GP provider from each CCG. The ethical framework takes into account the needs of the population and the needs of the community.

Links to Strategic Objectives (click on all boxes that apply) Effective Engagement. We will continually improve engagements with member practices, patients, the public, ☒ carers and our staff to contribute to and influence the work of Herts Valleys CCG. Quality. We will commission safe, good quality services that meet the needs of the population, reducing ☒ health inequalities and supporting local people to avoid ill health and stay well. Transforming Delivery. We will work with health and social care partners to transform the delivery of care ☐ through the implementation of “Your Care, Your Future”, the Strategic Review in west Hertfordshire and its fit with the wider STP strategy, “A Healthier Future”. Affordable & Sustainable Care. We will ensure that we fulfill our statutory duty to deliver a financially ☒ sustainable and affordable healthcare system in west Hertfordshire. Board Assurance Framework Refer to latest BAF report here for current and target risk scores: \\HVCCG-FS01\Shared\Nursing & Quality\8 Risk Management System\2. Board Assurance Framework\BAF 202021\Current versions for front sheet reference Ref. Risk Risk description Current risk Target risk *Assurance Owner score and score Level movement Example: *Refer to assurance levels table below. Risk that member practices, local providers, local authorities and other partners do not respond constructively to engagement. 1.2 LD/DE 12→ 8 Medium Assurance is provided that member practices are represented where recommendations are made by HMMC and MOCL. Risk that we are unable to ensure good quality, safe and sustainable services for the population and patients of west Hertfordshire. 2.2a JK 12→ 8 Medium Assurance is provided that recommendations made by HMMC or MOCL consider both clinical and cost effectiveness data. Risk that we do not deliver a financially sustainable integrated healthcare system in collaboration with our partners in the STP. 4.1 AP 20→ 5 Medium Assurance is provided that recommendations made by HMMC have effective stakeholder engagement across the STP. Risk that we do not achieve financial balance in 2020-21. 4.3 AP Assurance is provided that any recommendations 12→ 4 Medium made by HMMC or MOCL have oversight by the Primary Care Commissioning Committee. New strategic risks identified by this report

Other significant risks related to this report (from the Corporate Risk Register)

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Resource Total resource implication for this paper 20/21 : £-4K CFO Signature implications Total resource implication for this paper per annum: +£56.2K One off saving of (-£93K)

Medicines Optimisation Clinical Leads Meeting (MOCL)  Resource implications identified for implementation of the majority of MOCL decisions are none.  NB ScriptSwitch savings are already accounted for in QIPP targets 20/21 (-£4k) increasing to (-£61k) pa

Herts Medicines Management Committee (HMMC)

Item Cost to CCG Subcutaneous vedolizumab -£93K (one off saving) Sequential usetekinumab £13K pa and vedolizumab Naldemedine Max £58.2K pa NICE hypertension guidance £9K pa rising to £46k pa in year 5

Potential conflicts All conflicts of interest are declared and recorded as per the MOCL Terms of Reference that of interest were approved by the Primary Care Commissioning Committee in November 2019 and June 2018.

Potential and actual conflicts of interest are declared and recorded as per the HMMC Terms of Reference that were approved by the Primary Care Commissioning Committee in May 2019.

All Herts Valleys CCG GP members of the Primary Care Commissioning Committee are potentially conflicted as the matters within this paper refer to products under their prescribing control.

Any items which involve payment for GPs, GP members will be conflicted and these items will be reproduced in full so that non-GP members of the primary care commissioning committee can manage this conflict of interest. Equality impact . Recommendations made by MOCL have been through separate equality and quality impact assessments analyses as part of the review of all Pharmacy and Medicines Optimisation Team QIPP (EqIA) schemes. and . The HMMC ethical framework considers this element in each non-NICE recommended Quality Impact product assessment. Each equity and equality statement is reviewed by STP Equality and Assessments Diversity Lead. (QIA) . NICE considers equality as part of its NICE technology appraisal guidance recommendations. Please confirm that the EQIA has been reviewed and approved by Paul Curry, Equality and Diversity ☒ Lead [email protected] QIA guidance and templates can be found here: https://hertsvalleysccg.nhs.uk/index.php?cID=274&ctask=check- out&ccm_token=1589455689:d086eb2b318f0736d4fedaa33780c2ab Please confirm that the QIA has been reviewed and approved by Clare Molloy, Deputy Director ☒ EqIAs will be Nursing and Quality [email protected] published on the HVCCG website. Attach the approved analyses when submitting your draft and final reports. Decision makers are required to assure themselves that the reasons given for ‘none required’ are QIAs will be adequate. reported to the Indicate below the attachments accompanying your report and the key points the analysis has Quality Committee. identified, relevant to the decision required:

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EqIA attached ☒ Key points: see below EqIA attached for MOCL Paediatric Proton Pump Inhibitor Guidance The author has identified that there is expected to be positive impact in the Age protected characteristic and also for Carers, who the CCG treat as if they were a protected characteristic. It is likely that there is sufficient information for decision makers to be able to show due regard as required by the Equality Act 2010. Paul Curry, Equality, Diversity and Inclusion Lead, 2/11/20 EqIA not required for MOCL Scriptswitch papers. Equality impact statement added to each paper. Confirmed with Paul Curry 2.11.20 EqIA not required for MOCL paper Medicines Optimisatio nPharmacist approved list of actions. Confirmed with Paul Curry 3.11.20 EqIA not required for MOCL paper A guide to reducing antipsychotic prescribing for non-cognitive symptoms in dementia. Confirmed with Paul Curry 3.11.20 QIA part 1 attached ☐ Key points:

QIA part 2 attached ☐ Key points:

Equality delivery Does your paper provide supporting evidence for HVCCG’s EDS2 portfolio? system (EDS2) Please refer to EDS2 guidance here: https://www.england.nhs.uk/wp-content/uploads/2013/11/eds- nov131.pdf and indicate which goal your proposal/paper supports by clicking the appropriate box(es) Better health outcomes ☒ Improved patient access and experience ☒ A representative and supported workforce ☐ Inclusive leadership ☐ Data Protection Completion of a DPIA is not necessary in this case as ratification of the recommendations Impact within this paper will not change the way in which Herts Valleys CCG processes personal data Assessment nor will it result in the need to increase processing of personal data (DPIA) Confirm that your DPIA has been reviewed by the Information Governance Lead, approved by the ☐ Information Governance sub-group and is attached to your draft or final report Key outcomes and how they will be implemented:

Report history None. The current process requires the outputs from HMMC and MOCL to be reported to the relevant Herts Valleys CCG governing body. Appendices One

*Assurance levels – use this guide to identify the level of assurance indicated in the risk table above. Level Details **N.B. The executive summary for this paper should explicitly point to the evidence to support the assurance level indicated. For example: Very high – Where in the report is the evidence is to support the current strong position & how it will be sustained? High – Where in the report is evidence of what is being done to strengthen controls and mitigate the likelihood of this risk materialising? Medium – Where in the report is the evidence of what is being done to address gaps in assurance and how successful is this action proving? Low – Where in the report is a statement of the urgent actions planned to address the lack of assurance? Very high Taking account of the issues identified in this report, the Board can take reasonable assurance that the controls upon which the organisation relies to manage this risk are suitably designed, consistently applied and effective. High Taking account of the issues identified in this report, the Board can take reasonable assurance that the controls upon which the organisation relies to manage this risk are suitably designed, consistently applied and effective. However, we have identified issues that, if not addressed, increase the likelihood of the risk materialising. Medium Taking account of the issues identified in this report, whilst the Board can take some assurance that the controls upon which the organisation relies to manage this risk are suitably designed, consistently applied and effective, action needs to be taken to ensure this risk is managed.

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Low Taking account of the issues identified, the Board cannot take assurance that the controls upon which the organisation relies to manage this risk are suitably designed, consistently applied or effective. Action needs to be taken to ensure this risk is managed.

1. Executive Summary

HERTS VALLEYS CCG PHARMACY AND MEDICINES OPTIMISATION TEAM – SUMMARY REPORT October 2020

1. MEDICINES OPTIMISATION CLINICAL LEADS (MOCL) – SUMMARY OF RECOMMENDATIONS October 2020. The Primary Care Commissioning Committee is asked to ratify the recommendations reached by MOCL.

Table 1 summarises the recommendations made by MOCL. None of the recommendations commit new finances. MOCL papers are available on request.

Table 1 – recommendations of MOCL Budget adherence 2019- . For information. June 2020 data performance presented. 2020 Paediatric Proton Pump Recommended for publication by MOCL. EQIA attached Inhibitor guidance . The paediatric proton pump inhibitor guidance has been updated to remove costs and update recommended available PPI suspension. This work has been done with input from colleagues at West Herts Hospital Trust – no resource implications Care Homes For information -no resource implications . PRN (when required) medicine bite-sized training in care homes has been developed and shared . Bulk prescribing guidance was updated to remove dressings that are not prescription only. Recommended for publication by MOCL. EQIA not required A guide to reducing antipsychotic prescribing for non-cognitive symptoms in dementia was approved for publication ScriptSwitch For information. No EQIA required. . Recommended for addition to ScriptSwitch®. Three cost-saving switches have been identified and will be added to the prescribing support tool ScriptSwitch® to support cost-effective prescribing of medicines: o Switch generic desogestrel and all other brands of desogestrel to Desorex®.. o Switch from generic metformin MR tablets to branded Sukkarto MR tablets o Nebivolol tablets to be prescribed as 5mg for all doses (with the exception of patients where manual dexterity would be a problem for halving these tablets (2.5mg tablets are available). Likely financial impact if we achieve the expected 35% of switches offered = £4k. Annual saving is expected to be £61k (These savings are not new and are already included in the QIPP targets for cost effective prescribing) Documents For information –no resource implications . A publication is available on the HVCCG providing useful tips for Pharmacists working in GP Practices Recommended for publication by MOCL – no resource implications . Silk garments patient information leaflet . Medicines Optimisation Pharmacist approved list of actions. EqIA not required. A guide to actions that may be taken by a HVCCG medicines optimisation pharmacist when providing practice support without review by a practice GP was approved. . An implementation plan for Toujeo (insulin glargine 300units/ml) devised for HVCCG (and ENHCCG) by Hertfordshire Medicines Management Committee (HMMC) was recommended for implementation.

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For consideration by PCCC as GP voting members of MOCL declared a conflict of interest in this item. Local Incentive Scheme achievement update. . Local incentive scheme 20/21 (See appendix 1 for more detail) An update to the Local Incentive Scheme quality criteria was proposed to ensure that practices are better able to achieve these targets. This adjustment is needed because of the lag time between the reviews being made and the data being available to PMOT, and at the recommendations of the software provider. Payments based on this update would be as previously agreed within the budget set for payment of LIS 20/21. . Local incentive scheme 19/20 A COVID-19 adjustment is proposed to allow payment of the Oral Nutritional Supplement quality indicator for 19/20. This update would allow full payment of approximately 1/3 of practices and proportional payment according to achievement of 2/3 of practices. Payments based on this update would be as previously agreed within the budget set for payment of LIS 19/20 and ratified at PCCC in Aug 2020.

Palliative Care For information -no resource implications . Minor updates to re-use of medicines in care homes and hospices during the COVID -19 pandemic Stage 2 – Administration and recording of ‘just in case’ anticipatory medicines Risk Register For information Updated May 2020. All risks were reviewed and reassessed. MHRA drug safety alerts For information The primary care impacts were discussed and the details will be cascaded at prescribing locality meetings NICE For information . NICE documents from June to Aug 2020 were reviewed . Technical Appraisal Cost pressures for Herts Valleys CCG are assessed in section 2 below by Herts Medicines Management Committee. These are mandatory to be implemented and so this spend is not for discussion, just for local implementation.

2. HERTFORDSHIRE MEDICINES MANAGEMENT COMMITTEE (HMMC) – SUMMARY OF RECOMMENDATIONS July 2020

The Primary Care Commissioning Committee is asked to: a) Ratify the recommendations reached by HMMC on treatments that are not subject to NICE TAs; b) Note the mandatory NICE TAs published and likely impact of these on the commissioner’s budget; c) Note the national directives/initiatives that will impact on medicines optimisation.

a. Recommendations of HMMC on treatments that are not subject to NICE TAs.

Table 2 summarises the recommendations reached by HMMC on the following treatments that are not subject to NICE TAs. HMMC papers are available on request.

Table 2 – recommendations of HMMC on treatments that are not subject to NICE TAs Wound care – Formulary Recommended for use - Update to existing formulary. update Formulary harmonisation towards an ICS wide joint community wound

management products formulary. Some higher cost items have been added. Existing products have been reviewed and where appropriate lower cost items added. Overall it is expected that the changes will be cost neutral.

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Cost pressure not anticipated. Changes to Medicines Recommended for use - Processes for use during pandemic situation. Management during Pandemic Situation The process for changes to medicines utilised during the first wave was mapped and reviewed. Agreed that pharmacy cells to act as the key co-ordinating cells for prescribing decisions during any later phase of the pandemic.

Pharmacy cell membership to include the Chief pharmacists from commissioner and provider organisations (ENHCCG, HVCCG, ENHT, WHHT, HPFT, HCT, CLCH and LPC) and as during the pandemic to meet at least weekly to allow rapid escalation from internal provider processes/formulary meetings. Membership to be expanded to include the HMMC Chair where treatment decisions are to be discussed and relevant specialists to be invited as necessary.

For Herts Valleys cell proposed that the group report into a joint clinical forum (ICAG=integrated clinical and care advisory group) for ratification at board.

Streamlined paperwork developed for any applications to pharmacy cell.

This outlines a process – therefore no Cost pressure. – Supports preparatory measures for possible later phase of pandemic Vedolizumab subcutaneous Red status – Not for primary care prescribing - Recommend inclusion of (SC) for active crohn’s disease vedolizumab SC as an alternative for maintenance therapy to vedolizumab IV. and moderately to severe ulcerative colitis (UC) In June 2020 a licence extension was granted for vedolizumab SC as maintenance therapy following vedolizumab IV induction. Vedolizumab SC is lower cost compared to Vedolizumab IV. Therefore switching is recommended as an option for existing patients.

Vedolizumab is excluded from tariff and therefore the funding responsibility will be with CCGs.

One off cost saving – assuming 50% switch from IV to SC vedolizumab - £93k

Ustekinumab and Red status – Not for primary care prescribing – Recommended as an option - vedolizumab in the Sequential use of ustekinumab and vedolizumab in the UC pathway treatment pathway for moderately to severely active NICE recently recommended use of ustekinumab at the same place or as an ulcerative colitis (UC) alternative to vedolizumab in the UC treatment pathway. However NICE in their evaluation did not consider sequential use of ustekinumab after vedolizumab.

Local specialists expressed an interest in sequential use of ustekinumab and vedolizumab (as the drugs have different modes of action). An alternative in the pathway is tofacitinib which is lower cost than vedolizumab and ustekinumab. However there have been several safety concerns related to tofacitinib including thromboembolic and infection risk and a link to increased thrombotic risk with COVID. Specialists therefore indicate they are less likely to use tofacitinib. Surgery would be the most likely next treatment option but is usually avoided until it is the last available treatment option. Due to COVID there appears to be a backlog for elective surgery and there would be a potential risk of flare of disease and hospitalisation if treatment/surgery is not available.

Current practice is uncertain and therefore it is difficult to estimate to a cost pressure. If all patients who fail vedolizumab were treated with Ustekinumab the cost pressure would be £103k. However assuming that the additional cost pressure is from ustekinumab replacing tofacitinib in the pathway there would be an annual

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cost pressure of £13k

Ustekinumab, tofacitinib and vedolizumab are excluded from tariff and therefore the funding responsibility of CCGs.

An annual cost pressure of £13k is anticipated Melatonin (Slenyto®) tablets NOT recommended for prescribing in primary or secondary care (double red – all indications. status) in line with the East of England Priorities Advisory Committee (PAC).

The local NOT recommended position on Slenyto® is similar to that published by the Scottish Medicines Consortium and All Wales Medicines Strategy Group (as the case for cost effectiveness has not been proven).

Use Circadin® (as per previous HMMC decision - Feb 2020) where melatonin is indicated for children (under the age of 18 years) with formal confirmed diagnosis of attention deficit hyperactivity disorder (ADHD) or formal confirmed diagnosis of ASD (for the treatment of sleep disturbances).

Cost pressure not anticipated as this is a NOT recommended decision for Sleynto® brand of tablets.

Growth hormone Recommended for use – Status amber protocol (shared care with specialist) (somatropin) Use in Children Shared Care Protocol Update to existing shared care protocol to support appropriate and safe transfer of prescribing and monitoring responsibilities in line with recently agreed template and principles of shared care.

Cost impact is not anticipated as this is a replacement for an existing shared care protocol rather than change to the treatment available.

Guidelines for the Recommended for use – Update to existing guidelines. management of infections in Guidelines updated in line with Public Health England (PHE) and National Institute primary care for Health and Care Excellence (NICE) guidance. Where additional changes made these made in line with local specialists and stakeholder recommendation and engagement. Section on community acquired pneumonia updated with COVID-19 rapid guideline for managing suspected or confirmed pneumonia in adults in the community. Cost pressure is not anticipated

Hypertension guidance Recommended for use – Update to existing guidance – following recently updated NICE guidance on management of hypertension (not for pregnant women or people with type 1 diabetes). The guideline is anticipated to change prescribing for people with hypertension by offering antihypertensive drugs to people with a 10-year risk of CVD of at least 10% or more compared to the old guideline threshold of 20% or more. Estimated costs of previous practice for HVCCG are £770,368 (HV) and future practice is estimated to cost £816,864 (HV) by year 5 following gradual uptake and with potential savings taken in to account. The NICE resource impact tool estimates that for HVCCG there will be an additional cost of £46,496 by year 5. An annual cost pressure of up to £46k is anticipated. Items for noting Eight items were presented to HMMC for noting: o Adult Anticipatory JIC Medication and Syringe Pump Chart for use in SystmOne/Ardens and DXS – Minor amendments to electronic versions o Cow milk protein Allergy guidance update – Changes in pack size and product names. o Dry eye treatment guideline – product update

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o Varenicline PGD for supply via community pharmacy – for noting o Remdesivir for patients hospitalised with Covid-19 – [COVID-19 Therapeutic Alert and interim clinical commissioning policy and Supply Disruption Alert]. o Corticosteroids In Treatment Of Suspected Or Confirmed Covid-19 [COVID-19 Therapeutic Alert] o Lithium/Priadel® tablets discontinuation paused with Competition and Markets Authority (CMA) to investigate into suspected anti-competitive practices in the supply of drugs used to treat bipolar disorder. o Azathioprine/mercaptopurine HMMC agreed shared care published for implementation.

b. NICE Technology Appraisals (TAs) published 24th June 2020 – 7th October 2020 inclusive, and the financial implications.

Commissioners have a statutory responsibility to make funding available for a drug or treatment recommended by a positive NICE TA in line with criteria outlined in the NICE TA and to begin doing so within 90 calendar days (30 calendar days for products appraised via the Fast Track Appraisal process) of the guidance being published. CCG pharmacists work with local specialists to agree / clarify criteria for funding and to agree when the treatment is an ‘option’. Local pathways are updated with this information. For high cost drugs excluded from the national tariff, an application form is prepared and specialists are asked to submit these for all new patients.

As per the Primary Care Commissioning Committee agreement in March 2019, the necessity to seek formal approval before implementation of these TAs has been removed. From April 2019 onwards, the Primary Care Commissioning Committee will only receive a list of the NICE TA items that Herts Valleys CCG now has to provide for. This ensures that NICE TAs are implemented within the mandated timeframe.

Where NICE does not expect a TA to have a significant impact on resources they define this as less than £5M per year in England (or £9,100 per 100,000 population). Because of the large population in Herts Valleys CCG, the maximum anticipated cost pressure in these scenarios is £58,200 per year per TA.

Table 3 summarises the NICE TAs which are CCG commissioning responsibility.

Table 3 – NICE TAs which are CCG commissioning responsibility Note: When NICE does not expect this guidance to have a significant impact on resources; the impact for Herts Valleys CCG is a maximum of £58.2K per year.

Naldemedine for treating Naldemedine is recommended as an option for treating opioid-induced opioid-induced constipation constipation in adults who have had laxative treatment. [TA651] September 2020 NICE do not expect this guidance to have a significant impact on resources. For Herts Valleys CCG, this represents a maximum cost pressure of £58,200 per annum. This is because naldemedine is a further treatment option and the overall cost of treatment will be similar to the current treatment options available.

Naldemedine is an in-tariff drug. Services for opioid-induced constipation are provided in both primary and secondary care.

The implementation of this TA requires consultation with primary care and local specialists – to be discussed at December 2020 HMMC meeting.

HMMC GREEN status - (Recommended for prescribing in primary and

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secondary care)

c. MHRA drug safety updates June to Sept 2020.

Recent MHRA drug safety updates from June to Sept 2020 were outlined. Safety messages will be highlighted at Locality Prescribing Leads meetings and disseminated to Community Pharmacists where agreed.

Appendix 1

LIS 20/21 indicator

An update to the Local Incentive Scheme quality criteria is proposed to ensure that practices are better able to achieve the targets set out in the quality component of the Local Incentive Scheme 20/21. This scheme was approved by PCCC in Jan 2020 and is designed to improve patient care and to prevent avoidable admissions. Clinicians are required to address red and amber admission avoidance alerts in the Eclipse Live system and targets have been set for reviewing red and amber alerts. Adjustment of these alerts is needed because of the lag time that has been identified between the reviews being made and the data being available to PMOT, and at the recommendations of the software provider.

Proposal • There will be no change to Q1 target. • To amend the Q2 and Q4 thresholds for maximal payment to 85% of red alerts reviewed between April and Sept 2020 and 85% of red and amber alerts reviewed between April 2020 and March 2021 respectively (previous targets were 100%). • To amend the Q3 target to 65% of red and amber alerts reviewed between April 2020 and Dec 2020 (previous target was 75%)

Background The Eclipse Live RADAR alert searches are run within the secure Advice & Guidance (Eclipse Live) Database each week to identify patients at risk and in need of intervention. Alerts identified may be tasked by a member of GP practice staff and actioned by an appropriate clinician. Acknowledgement of the alert in the Eclipse Live system is collated by Prescribing Services to provide information on the percentage of alerts reviewed by each practice. This governs the quality aspect of the LIS payment for 20/21. If a GP practice addresses a clinical factor that has triggered an alert and subsequently do not task or review the alert in Eclipse Live the alert will disappear when the next weekly data retrieval is undertaken. This alert will be marked in the Eclipse Live report as ‘unreviewed’ and will bring the percentage of reviewed alerts for that practice down. We propose to reduce the percentage of alerts that we require to be reviewed to achieve full quality component payment to ensure that practices are not disadvantaged for good clinical practice. We believe that we have good clinical engagement with implementing these alerts. Other CCGs have shown that where practices implement alerts admissions are reduced by 5-10% which will produce substantial savings on admission. We cannot prove similar benefits in Herts Valleys CCG, although they seem likely, unless we subscribe to Eclipse Vista, which is an add on programme linking Eclipse to admissions data.

Financial implications

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The Local incentive scheme for GPs 20/21 was approved by PCCC in January 2020. The maximum resource involved in the quality component of the incentive scheme is 20p per weight adjusted patient which converts into up to £127,000/year, although in previous years typically 2/3 of the total LIS budget is spent. The proposed update to the scheme does not affect the overall payment achievable. The update will provide the opportunity for practices to better achieve incentive payments for their participation in the scheme and will promote clinician engagement. The cost of the scheme will be offset by reduced admission rates, which is also beneficial during times of acute Covid19 admissions.

LIS 19/20 ONS indicator

Proposal We would like to apply a COVID adjustment to the targets for the LIS 19/20 oral nutritional supplements indicator.

Background This indicator is worth 5p per PNW patient (max expected payment approx £30k). The targets have been altered to allow full payment (green) of approximately 1/3 of practices and proportional payment according to achievement of 2/3 of practices (some of these who have not moved from baseline will have no payment for this indicator).

Financial Implications This is in keeping with our usual LIS payments year on year and our predicted payment for this indication that was agreed by PCCC a paper. The PCCC statement that was agreed at PCCC in Aug 2020 is copied below.

‘The oral nutritional supplement component payment data is not available at the time of writing this paper as practices were permitted extra time to fulfil this aspect of the local incentive scheme. The expected payment will be between £15k and £25k’.

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Equality Analysis

Title of policy, service, proposal etc being assessed: Proton Pump Inhibitor (PPI) use in paediatric patients – joint guidance for primary and secondary care.

What are the intended outcomes of this work? Include outline of objectives and function aims

This EqIA is being completed as the guidance has been updated.

The updates to the guidance are: - Lansoprazole 5mg/5ml oral suspension (unlicensed) is now alcohol free and therefore has been included in section A3. - Prices of products removed as these are constantly changing. For information, all unlicensed ‘specials’ have reduced in cost (Drug Tariff, June 2020). - SodiBic® 420mg/5ml (1mmol/ml) oral solution removed as this has been discontinued.

This guidance was first produced In May 2018 as there was no established guidance for PPI prescribing for paediatrics in West Hertfordshire. Paediatrics are a vulnerable group of patients for whom dosing and choice of medication is difficult.

How will these outcomes be achieved? What is it that will actually be done? What is it that the proposal will stop, start or change?

This guidance can be referred to when choosing the most appropriate formulation of PPI for a paediatric patient. The joint guidance allows streamlined care across the primary and secondary care interface and will have the following benefits:  Reduced prescribing costs  Improvement in quality of care

Who will be affected by this work? e.g. staff, patients, service users, partner organisations etc. If you believe that there is no likely impact on people explain how you’ve reached that decision and send the form to the equality and diversity manager for agreement and sign off

Prescribers in primary and secondary care, and paediatric patients requiring PPIs will be affected by this guidance. There will be a positive impact due to consistent approach to prescribing proton-pump inhibitors in paediatrics across primary and secondary care.

Evidence

Impact Assessment Not Required There may be occasions the papers presented do not require a decision and/or will have no impact (positive or negative) on people from the equality and health inequality groups, for example papers presented for information or for assurance. Where you can show that this is the case use this box to explain why. You will not need to complete the rest of the template. The template will still need to be sent to Paul Curry who will, if it is the case, confirm that no equality impact assessment is required.

Impact Assessment Required What evidence have you considered? Against each of the protected characteristics below list the main sources of data, research and other sources of evidence (including full references) reviewed to determine impact on each equality group.

If you are submitting no evidence against a protected characteristic, please explain why.

If there are gaps in evidence, please state how (and when) you will gather evidence and review the equality impact assessment in the Next Steps section of this document.

Evidence for all groups could include population data and service usage data,

Age Consider and detail age related evidence. This can include safeguarding, consent and welfare issues.

This guidance is only applicable to paediatric patients and is an update to an existing guidance. The guidance applies to all relevant patients. Appropriateness of medicines for individual patients is a clinical decision by the prescribing clinician. This means that there will not be a direct or indirect impact on the patient because of their equality group status. Guidance for adults in outside of the scope of this guidance.

Disability Detail and consider disability related evidence. This can include attitudinal, physical and social barriers as well as mental health/ learning disabilities.

Congenital disabilities in children, such as, (but not limited to), birth defects, neurological impairment, Down’s Syndrome or neurodisability (cerebral palsy) might mean a paediatric patient is at greater risk of higher production of acid, this guidance can help to manage one of the consequences of their disability, and therefore have a positive impact on this group.

Gender reassignment (including transgender) Detail and consider evidence on transgender people. This can include issues such as privacy of data and harassment.

No differential impact anticipated.

Marriage and civil partnership Detail and consider evidence on marriage and civil partnership. This can include working arrangements, part-time working, caring 2

responsibilities.

No differential impact anticipated.

Pregnancy and maternity Detail and consider evidence on pregnancy and maternity. This can include working arrangements, part-time working, caring responsibilities.

No differential impact anticipated.

Race Detail and consider race related evidence. This can include information on difference ethnic groups, Roma gypsies, Irish Travellers, nationalities, cultures, and language barriers.

No differential impact anticipated.

Religion or belief Detail and consider evidence on people with different religions, beliefs or no belief. This can include consent and end of life issues.

No differential impact anticipated.

Sex Detail and consider evidence on men and women. This could include access to services and employment.

No differential impact anticipated.

Sexual orientation Detail and consider evidence on heterosexual people as well as lesbian, gay and bisexual people. This could include access to services and employment, attitudinal and social barriers.

No differential impact anticipated.

Carers Detail and consider evidence on part-time working, shift-patterns, general caring responsibilities.

The guidance has a positive impact for carers as it ensures the appropriate formulation is chosen and it makes the medication easier to administer.

Other identified groups Detail and consider evidence on groups experiencing disadvantage and barriers to access and outcomes. This can include different socio- economic groups, geographical area inequality, income, resident status (migrants, asylum seekers).

No differential impact anticipated.

Engagement and involvement

How have you engaged stakeholders with an interest in protected characteristics in gathering evidence or testing the evidence available?

This guidance has been developed in conjunction with West Herts Hospital Trust. It has been approved by the Trust Drugs Committees (TAC and MUSP), and neonatologists are in agreement with the guidance. This is an update to an existing guidance that was first approved by the Herts Valleys CCG Medicines Optimisation Clinical Leads (MOCL) group, and ratified at Herts Valleys CCG Primary Care Commissioning Committee (PCCC) in May 2018. The guidance has been adopted by many trusts and CCGs in East of England.

How have you engaged stakeholders in testing the policy or programme proposals?

This is an update to an existing guidance.

For each engagement activity, please state who was involved, how and when they were engaged, and the key outputs:

This is an update to an existing guidance.

Summary of Analysis

Considering the evidence and engagement activity you listed above, please summarise the impact of your work. Consider whether the evidence shows potential for differential impacts, if so state whether adverse or positive and for which groups and/or individuals. How you will mitigate any negative impacts? How you will include certain protected groups in services o r expand their participation in public life?

Positive impact identified for paediatric patients and carers.

Now consider and detail below how the proposals could support the elimination of discrimination, harassment and victimisation, advance the equality of opportunity and promote good relations between groups. This is the part of the Public Sector Equality Duty (see page 2).

Eliminate discrimination, harassment and victimisation

This policy is a proposal to amend the prescribing guidance for proton-pump inhibitors in pediatrics across primary and secondary care. Consideration of the three aims of the general equality duty does not apply in this case.

Advance equality of opportunity

Promote good relations between groups

Next Steps

Please give an outline of what you are going to do, based on the gaps, challenges and opportunities you have identified in the summary of analysis section. This is your action plan and should be SMART.

The guidance will be reviewed every 3 years as per the Pharmacy and Medicines Optimisation Team (PMOT) governance process, or earlier in light of new information that affects the guidance.

How will you share the findings of the Equality analysis? This can include sharing through corporate governance or sharing with, for example, other directorates, partner organisations or the public. The completed EqIA will be published on the Herts Valleys CCG website either as part of the report on the proposals or separately on the equality and diversity pages.

The completed Equality Impact Assessment will be published on the Herts Valleys CCG website and sent to WHHT.

Health Inequalities Analysis

Evidence

1. What evidence have you considered to determine what health inequalities exist in relation to your work? List the main sources of data, research and other sources of evidence (including full references) reviewed to determine impact on each health inequality group. If there are gaps in evidence, state what you will do to mitigate them.

Not applicable Impact

2. What is the potential impact of your work on health inequalities? Can you demonstrate through evidenced based consideration how the health outcomes, experience and access to health care services differ across the population group and in different geographical locations that your work applies to?

Not applicable

3. How can you make sure that your work has the best chance of reducing health inequalities?

Not applicable

Monitor and Evaluation

4. How will you monitor and evaluate the effect of your work on health inequalities?

Not applicable

For your records Name of person(s) who carried out these analyses: Radhika Kotecha

Date analyses were completed: 2nd November 2020

Equality and Diversity Lead Sign off

The author has identified that there is expected to be positive impact in the Age protected characteristic and also for Carers, who the CCG treat as if they were a protected characteristic.

It is likely that there is sufficient information for decision makers to be able to show due regard as required by the Equality Act 2010.

Paul Curry, Equality, Diversity and Inclusion Lead, 2/11/20

Title of scheme: ScriptSwitch Savings CCGs covered by the scheme: Herts Valleys CCG and East and North Herts CCG Project Lead for scheme: Sarah Crotty Senior Manager/ Executive Sponsor: Rachel Joyce Brief description of scheme: Herts Valleys CCG Pharmacy & Medicines Optimisation Team (PMOT) ensures the optimum use of medicines for the Herts Valleys CCG patient population. This work includes reviewing the range of medicines in use locally. Where possible, suggestions are made to encourage switches where a suitable alternative medicine is available that is provided by an alternative manufacturer at a reduced cost to the alternative(s) currently in routine use. Indications, dosages, administration details, patient numbers and market availability are considered before recommending the switch. The intention is to improve cost effectiveness without any impact on quality. Intended Quality Improvement Outcome/s: The switches (which may be from brand to generic or from generic to a preferred brand) are recommended to optimise medicines use for patients served by Herts Valleys CCG and East and North Herts CCG. Work is done in advance to ensure that there are no patient safety or adverse quality impact of the suggested switches. Where possible (e.g. where switching to a preferred brand) we work with the acute trusts to ensure we all use the same products as 1st choice. This can reduce the number of changes in appearance of medications and so reduce confusion for patients. Acute Trusts usually use generic medicines 1st line unless we have agreed a branded switch and so our usual policy of using generic medicines or named brands agreed with the Trusts improves continuity for patients and helps us work towards our ultimate aim of using similar products in every care setting. Methods to be used to monitor quality impact: Planned proposed switches are reviewed by the Medicines Optimisation Clinical Leads committee to ensure that the switch is appropriate and will not adversely affect the patient population receiving the medication. Each switch is monitored by the Pharmacy Medicines Optimisation ScriptSwitch staff and feedback is encouraged from health care professionals. Any complaints to PMOT are thoroughly investigated and if required a switch could be removed from ScriptSwitch the same day. This capability is very powerful but has not been required over the last few years due to the selective nature of our process for suggesting switches.

Pos/ Risk Comments (include reason for identifying impact as Full Assessment Neg Score positive, negative or neutral) Required or if N Yes/No N/A (Risk > 8 Stage 2 full assessment required) Duty of Quality Could the proposal impact positively or negatively on any of the following:

a) Compliance with NHS Constitution Neutral right to: The switches do not impact on the provision of medication to patients. All patients are entitled

 Quality of Care and Environment to receive treatment as per local and national  Nationally approved treatments/ guidelines. drugs National guidelines suggest that CCGs have a  Respect, consent and duty of care to prescribe in a cost effective confidentiality manner. NHSE have in the past incentivised the  Informed choice and involvement use of generic medicines, as the gold standard.  Complain and redress

The suggested switches are reviewed and Neutral implemented in partnership with primary care b) Partnerships colleagues and where possible with secondary care for Branded medicines switches.

N/A c) Safeguarding children or adults

NHS Outcomes Framework

Could the proposal impact positively or negatively on the delivery of the five domains (assess all separately): 1. Preventing people from dying Neutral Good Medicines optimisation practice will ensure prematurely best outcomes from medicines. Neutral Good Medicines optimisation practice will ensure 2. Enhancing quality of life best outcomes from medicines.

3. Helping people recover from Neutral Good Medicines optimisation practice will ensure episodes of ill health or following best outcomes from medicines. injury Neutral Good Medicines optimisation practice will ensure 4. Ensuring people have a positive best outcomes from medicines. experience of care N/A 5. Treating and caring for people in a safe environment and N/A protecting them from avoidable harm Access Could the proposal impact positively or Switches are not mandatory and are suggested negatively on any of the following: Neutral only. If a patient wishes to continue on their current ‘brand’ of medicine this could be possible a) Patient Choice after discussion with their clinician. b) Access

c) Integration Risk score = 0

Name of person completing assessment: Janet Weir Position: Senior Pharmaceutical Advisor, Pharmacy Medicines Optimisation Team Signature: Janet Weir Date of assessment: 3/11/20

Reviewed by: Sarah Crotty Position: Head of Pharmacy Medicines Optimisation

Signature: Date of review: 3/11/2020 Proposed frequency of review: Six monthly/ Quarterly/ Monthly/ Other please specify: 6 months

(minimum monitoring is six monthly (scores 6 or below), every 4 months (scores 8-9), quarterly (scores 10- 12) and monthly (15-20), weekly or more frequent (score 25) Use boxes below to record outcome of reviews

Date of next review:

Signed off by: Clare Molloy Position: Deputy Director of Nursing and Quality

Signature: Date of review: 10/11/2020 Requires review at Quality Committee: Y/N Date considered at Quality Committee:N/A Logged on spreadsheet: Y Date: 10/11/2020

Post Implementation Review (use the template below to record outcomes of reviews- if more than one is required cut and paste the box below) Have the anticipated quality impacts been realised? Y/N Comments: Have there been any unanticipated negative impacts? Y/N Comments: Are any additional mitigating actions required? Y/N Comments: Do any amendments need to be made to the scheme? Y/N Comments: Reviewed by:

Position: Signature: Date of review: